The nurse reviews the following in the medical record of a 2 day post cesarean delivery postpartum client. Temperature of 101° F, heart rate of 110, complaints of chills, incision with erythema in the center, and WBC count of 25,000 mm3. What are three (3) priority actions that should be implemented? Suggested Maternal Newborn Learning Activity: Postpartum Infection
In the case described, the nursing priority is to identify and address the potential postpartum infection that the client might be experiencing. Postpartum infections are common complications following cesarean deliveries, and they can range from mild cases to severe, life-threatening conditions. Identifying and addressing the infection promptly is crucial to ensure the wellbeing of the mother and prevent any further complications.
The three priority actions that should be implemented in this scenario are as follows:
1. Assess and monitor the client’s vital signs: As the client has a temperature of 101° F and a heart rate of 110, it indicates signs of infection, specifically the presence of fever. Monitoring the client’s vital signs, including temperature, heart rate, respiratory rate, and blood pressure, is essential to identify any changes in the client’s condition. Frequent monitoring will help determine the progression or regression of the infection or any other associated complications. It is important to document these vital signs accurately and consistently throughout the assessment period to track the progress of the infection and the effectiveness of the interventions.
2. Evaluate the incision site: In this case, the client’s incision shows erythema in the center, indicating localized inflammation. Assessing the incision site is crucial as it helps in determining the extent and severity of the infection. The nurse should carefully inspect the incision for signs of infection such as redness, warmth, swelling, and drainage. Documentation of the characteristics of the incision site is essential to track any changes over time. Additionally, assessing the surrounding skin for signs of cellulitis or abscess formation is also important.
3. Obtain and interpret the complete blood count (CBC) results: The client’s WBC count of 25,000 mm3 indicates an elevated white blood cell count, which is one of the body’s natural immune responses to infection. However, a significantly high WBC count suggests a more severe infection or systemic response. Obtaining the complete blood count with differential will provide valuable information to assess the client’s immune response and severity of infection. The differential count helps to identify specific types of white blood cells, such as neutrophils, which play a crucial role in fighting off infections. Analyzing the CBC results will help establish the severity of the infection and aid in determining the appropriate interventions and treatment plan.
Once these priority actions have been implemented, additional interventions may be necessary depending on the findings. These interventions may include initiating antibiotics, promoting rest and adequate nutrition, educating the client on signs and symptoms of infection, and ensuring effective communication with other healthcare providers involved in the client’s care. The nurse should also consider promoting infection prevention strategies, such as hand hygiene and proper wound care, to minimize the risk of further complications and spread of infection.
In conclusion, when confronted with a post cesarean delivery postpartum client with signs and symptoms of infection, three priority actions should be implemented. First, monitoring and assessing vital signs is crucial to track the client’s condition. Second, evaluating the incision site helps identify the extent and severity of infection. Lastly, obtaining and interpreting the complete blood count results aids in assessing the client’s immune response and severity of infection. By implementing these priority actions promptly, the nurse can effectively care for the client, identify complications early, and facilitate appropriate interventions to promote recovery and prevent further complications.