NURSING DIAGNOSIS: Risk for infection

  1. wound infection related to:
    1. wound contamination associated with introduction of pathogens during or following surgery (especially with a perineal approach because incision is close to the anus)
    2. delayed wound healing associated with factors such as diminished tissue perfusion of wound area (especially if client received external radiation therapy prior to surgery) and decreased nutritional status (if present);
  2. urinary tract infection related to:
    1. introduction of pathogens associated with presence of indwelling catheter
    2. increased growth and colonization of microorganisms associated with urinary stasis (can occur with decreased activity and catheter obstruction).
Desired Outcome
The client will remain free of wound infection (see Standardized Postoperative Care Plan, Diagnosis 17, for outcome criteria).
Nursing Actions and Selected Purposes/Rationales
  1. Refer to Standardized Postoperative Care Plan, Diagnosis 17, for measures related to assessment and prevention of wound infection.
  2. If a perineal approach was used, implement additional measures to prevent wound infection:
    1. instruct and assist client to perform good perineal care immediately after bowel movements
    2. use a double-tailed T-binder, scrotal support, or jockey shorts to secure perineal dressings (movement of loose dressings can cause skin irritation and subsequent breakdown).