Nursing Care Plan for Neonatal Sepsis NCP

Student Nurses’ Community ASSESSMEN T

DIAGNOSIS

INFERENCE

NURSING CARE PLAN ─ Neonatal Sepsis PLANNING

INTERVENTION

RATIONALE

EVALUATI ON

Body substance isolation (BSI) should be used for all infectious patients. Reverse isolation/restric ti on of visitors may be needed to protect the immunosuppre ssed patient. Reduces risk of cross contamination because gloves may have noticeable defects, get torn or damaged during use. Prevents spread of

After 8 hours of nursing interventio ns, the patient was able to achieve timely healing and free from further infection.

SUBJECTIVE: “Walng gana dumede ang anak ko, parang mainit sya at matamlay” (it’s difficult to feed my baby, she feels warm to touch & not very active) as verbalized by the mother. OBJECTIVE: • Increased body temperature. • Flushed skin. • Increased respiratory rate.

Risk for infection related to compromise d immune system.

Sepsis is a clinical term used to describe symptomatic bacteremia, with or without organ dysfunction. Sustained bacteremia, in contrast to transient bacteremia, may result in a sustained febrile response that may be associated with organ dysfunction. Septicemia refers to

After 8 hours INDEPENDENT: of  Provide isolation nursing and monitor intervention visitors as s, indicated. the patient  Wash hands will before or after achieve each care timely activity, even healing and gloves are free used. from further  Limit use of infection. invasive devices or procedure as possible.  Inspect wounds or site of invasive devices, paying particular attention to parenteral lines.  Maintain sterile technique when changing

Student Nurses’ Community • V/S taken as follows: T: 37.7 P: 130 R: 45

the active multiplication of bacteria in the bloodstream that results in an overwhelming infection.

dressings, suctioning or providing site care.  Provide tepid sponge bath and avoid use of alcohol.  Observe for chills and profuse diaphoresis.  Monitor for signs of deterioration of condition or failure to improve in therapy. COLLABORATIVE:  Obtain specimens of urine, blood, sputum, wound as indicated for gram stain, and sensitivity.  Administer antibiotics as prescribed.

infection via airborne droplets. May provide clue to portal entry, type of primary infecting organisms, as well as early identification secondary infection. Prevents introduction of bacteria, reducing risk of nosocomial infection. Used to reduce fever. Chills often precede temperature spikes in presence of generalized infection. May reflect inappropriate antibiotic

Student Nurses’ Community therapy or overgrowth of secondary infections. Identification of portal entry and organism causing the septicemia is crucial in effective treatment. To prevent further spread of infection.