High Risk for Infection related to Inadequate Primary Defenses Secondary to post

1. High Risk for Infection related to Inadequate Primary Defenses Secondary to post-operative Surgical Incision. Assessment Planning Implementation Evaluation Subjective:  Not applied Objective: - Presence of Post- operative incision wound  2.54 cm horizontally with suture and dressing - Increased environmental exposure - Immaturity of the Immune System at Birth . Short-term Goal: Within 8 hours of nursing interventions, the patient will: Maintain a temperature within normal range (36.4 – 37.4 degrees Celsius) Achieve reduction of risks for infection Be in a safe environment Long-term Goal: At the end of 3 weeks of nursing intervention the patient will:  Achieve timely wound healing; be free of purulent drainage; and remain afebrile. .  Stressed proper hand washing techniques by all caregivers between therapies .  R: This is a first-line defense against nosocomial infections or cross- contaminations .   Instructed mother in techniques to protect the integrity of skin, and prevention of spread of infection .  R: Knowledge in infection control is helpful in the prevention of spread of infection   Encouraged mother to update immunizations as appropriate .  R: Immunizations increases the child’s secondary defenses that help in fighting against microorganisms that may cause infection. GOALS MET as supported by the following manifestations: - Temperature: 37.0 degrees Celsius - Absence of signs of infection on wound - Wound has closed; no more suture and dressing and timely wound healing is achieved.