Risk for Infection | Nursing Care Plan for Appendectomy

Nursing diagnosis: risk for Infection

Risk factors may include
Inadequate primary defenses, perforation or rupture of the appendix, peritonitis, abscess formation
Invasive procedures, surgical incision

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Wound Healing: Primary Intention
Achieve timely wound healing, free of signs of infection and inflammation, purulent drainage, erythema, and fever.

Nursing intervention with rationale:
1. Practice and instruct in good hand-washing and aseptic wound care. Encourage and provide perineal care.
Rationale: Reduces risk of spread of bacteria.

2. Inspect incision and dressings. Note characteristics of drainage from wound or drains (if inserted) and presence of erythema.
Rationale: Provides for early detection of developing infectious process and monitors resolution of preexisting peritonitis.

3. Monitor vital signs. Note onset of fever, chills, diaphoresis, changes in mentation, and reports of increasing abdominal pain.
Rationale: Suggestive of presence of infection, developing sepsis, abscess, and peritonitis.

4. Obtain drainage specimens, if indicated.
Rationale: Gram’s stain, culture, and sensitivity testing is useful in identifying causative organism and choice of therapy.

5. Administer antibiotics, as appropriate.
Rationale: Antibiotics given before appendectomy are primarily for prophylaxis of wound infection and are not usually continued postoperatively. Therapeutic antibiotics are administered if the appendix is ruptured or abscessed, or peritonitis has developed.

6. Prepare for and assist with incision and drainage (I&D) if indicated.
Rationale: May be necessary to drain contents of localized abscess.