ASSESSMENT S: Ilan oras pa lang naooperahan ang anak ko basang basa na agad ang gasa nya.

O: -Slightly soaked dressing on the right lower quadrant -Foley catheter connected to urine bag Vital sign as follows: Temp: 37.3 C RR: 23 cpm PR: 120 bpm BP: 90/ 60 mm Hg

NURSING DIAGNOSIS Risk for infection related to breakdown of the primary defense secondary to appendectomy.

SCIENTIFIC EXPLANATION Appendectomy is an intentional incision at the Mc. Burney points to facilitate the removal of vermiform appendix. Breaks in the integument, the bodys first line of defense, is a potential site for invasion by pathogens or microorganism. And the moist environment predispose to infection because it promotes bacterial growth and bacteria moves fast on a wet environment compare to dry.

PLANNING

INTERVENTION Independent: The Nurse will: Monitor vital signs especially temperature. Observe for shaking chills and profuse diaphoresis.

RATIONALE

EXPECTED OUTCOME After series of nursing intervention, the patient will prevent infection from incision site as evidenced by normal vital signs, and absence of purulent drainage, swelling and inflammation from the appendectomy site.

After 8 hours of nursing intervention, the patient will remain free from infection.

-To establish baseline date and assess any changes. Chills often precede temperature spikes in presence of generalized infection -This reduces the number of organisms in patients environment and limiting visitation reduces the transmission of pathogens to the patient at risk for infection

Limit visitors

Maintain asepsis for -To reduce the risk dressing changes and of microorganism wound care. Change invasion dressing once a day and check for symptoms of infection such as redness on

Reference: Gulanick, Klopp, Galanes, Gradishar, Puzas (1994), Nursing Care Plans: Nursing Diagnosis and Intervention, Mosby-year book inc. 3rd edition, p.40-41. Porth, Carol Mattson. (2002), pathophysiology : concepts of altered health states, lippincott williams and wilkins publishing company, p.319

the incision site. Emphasize proper hand washing techniques and wash hands frequently Inform relatives the importance of avoiding contact with those who have infections or colds. Encourage early ambulation, deep breathing, coughing, position changes. -Serves as 1st line of defense against infection and microorganism transmission -To prevent the patient from acquiring microorganisms from patients who are already infected -For mobilization of respiratory secretions and prevention of aspiration/respirator y infections

Maintain adequate -To prevent hydration and imbalances that electrolyte balance would predispose to infection Provide/encourage balanced diet, emphasizing proteins to feed the immune system. -Immune function is affected by protein intake and adequate amounts of vitamins A, C, and E and the minerals

zinc and iron. Dependent: Administer Cefuroxime Metronidazole doctors order at right time, dose frequency. Collaborative: Obtain specimen for -Verifies the culture/ sensitivity presence of infection, identifies specific pathogens, and influences choice of treatment Monitor white blood cells including neutrophils, lymphocytes, monocytes, eosinophils and basophils) -Follows progress and effects of disease process/therapeutic regimen, and facilitates necessary alterations in therapy. -These antibiotics and are toxins to per infectious pathogens the and