Student Nurses’ Community

NURSING CARE PLAN ─ Neonatal Sepsis

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
Risk for Sepsis is a clinical After 8 hours of INDEPENDENT: Body substance After 8 hours
“Walng gana infection related term used to nursing  Provide isolation isolation (BSI) of
dumede ang anak to compromised describe interventions, and monitor visitors should be used for nursing
ko, parang mainit immune symptomatic the patient will as indicated. all infectious interventions,
sya at matamlay” system. bacteremia, with or achieve timely  Wash hands before patients. Reverse the patient
(it’s difficult to without organ healing and free or after each care isolation/restricti was
feed my baby, she dysfunction. from further activity, even gloves on of visitors may able to
feels warm to Sustained infection. are used. be needed to achieve
touch & not very bacteremia, in  Limit use of invasive protect the timely healing
active) as contrast to devices or immunosuppressed and free from
verbalized by the transient procedure as patient. further
mother. bacteremia, may possible. Reduces risk of infection.
result in a  Inspect wounds or cross
OBJECTIVE: sustained febrile site of invasive contamination
• Increased body response that may devices, paying because gloves
temperature. be associated with particular attention may have
• Flushed skin. organ dysfunction. to parenteral lines. noticeable defects,
• Increased Septicemia refers  Maintain sterile get torn or
respiratory rate. to technique when damaged during
the active changing dressings, use.
• V/S taken as multiplication of suctioning or Prevents spread of
follows: bacteria in the providing site care. infection via
T: 37.7 bloodstream that  Provide tepid airborne droplets.
P: 130 results in an sponge bath and May provide clue
R: 45 overwhelming avoid use of alcohol. to portal entry,
infection.  Observe for chills type of primary
and profuse infecting
diaphoresis. organisms, as well
 Monitor for signs of as early
identification
Student Nurses’ Community
deterioration of secondary
condition or failure infection.
to improve in Prevents
therapy. introduction of
bacteria, reducing
COLLABORATIVE: risk of nosocomial
 Obtain specimens of infection.
urine, blood, Used to reduce
sputum, wound as fever.
indicated for gram Chills often
stain, and precede
sensitivity. temperature spikes
 Administer in presence of
antibiotics as generalized
prescribed. infection.
May reflect
inappropriate
antibiotic 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.