ASSESSMENT NDX RATIONALE PLANNING INTERVENTION RATIONALE EVALUATIOM

>post exlap Risk for Inflamed appendix and >after 3 days of 1. Monitored 1.Elevated WBC >After 3 days of
>c dressing, dry infection r/t ruptured mesenteric tumor nursing and WBC. count indicates nursing and
and intact post surgical collaborative infection. collaborative
>wbc:10.88 procedure as interventions 2.advised and 2.proper interventions,
>afebrile(T: ) manifested by Exlap,evacuation of the nurse would instructed the handwashing the goal was
elevated WBC hemoperitoneum be able to: patient and prevents cross met as
count segmental ileal resection 1. Promote relatives to contamination. evidenced by
anastomosis,appendectomy infection control perform proper the patients
and minimizes handwashing understanding
risk for before and after of infection
infection. wound care. control and
Incision in the midline of 2.Prevent 3.Assessed 3.To determine determination
the abdomen further dressing for if the secretions of early signs
complications. purulent are normal. and symptoms
discharge, of infection.
noting
Damaged tissue and characteristics
integument , then and amount of
inflammation response secretion.
WBC increases 4.Cleansed 4.To prevent
incision site invasion of
aseptically. microorganism.
5.Changed 5.To maintain
Portal of entry for wound dressing cleanliness and
microorganisms aseptically. dryness of the
dressing.
6.Encouraged to 6.Having good
maintain nutrition and
Increased risk for infection hydration and proper hydration
adequate will strengthen
nutrition. the immune
system and
 improve bodies
defense against
infection.
7.Instruct client 7.The skin is the
in techniques to first line of
protect the defense against
integrity of the infection so it
skin should be intact.
8.Observed for 8.To identify and
untoward signs determine
and symptoms. impending
complications.
9.Due available 9.Medications
medications improves
given as patients
prescribed. condition and
prevent
infection.
10.Assessed 10.To determine
clients response the effectiveness
to the of therapy and
medications. presence of side
effects.
11.Vital signs 11.to obtain
checked and baseline data.
recorded.