AssessmentNursing DiagnosisOutcomeNursing InterventionsEvaluation

StandardCriteria

Subjective:

Objective:

Patient is diagnosed with neonatal sepsis upon admission

Vital SignRR;43cycles/min

HR:152 bpm

TEMP: 36.8

WT: 2.94 kg

Increased WBC level 29.3 Risk for infection r/t spread of pathogens secondary to identified sepsis and immature immune system

Scientific reason:

The newborns immune system is not fully activated until sometime after birth. Limitation in the newborns inflammatory response result in failure to recognize, localize, and destroy invasive bacteria thus, increasing risk for infectionShort term goal:After 8 hrs of nursing interventionthe infant will free from further infection

Long term goal: After several days of nursing intervention infection will be prevented.

INDEPENDENT

1. assess TPR &BP, auscultate breath sounds Assessments provide information about the spread of infection, increased RR and HR, decreased BP are signs of sepsis. Spread of infection may cause resp. distress

.2. Ensure that all people coming in contact with infant wash their hands well before & after touching the baby

Hand washing prevents the spread of pathogens coming from the infant to the caregiver and vice versa

3. Ensure that all equipment used for infant is sterile, scrupulously clean &disposable. Do not share equipment with other infants this would prevent the spread of pathogens to the infant from equipment

4. Place infant in isolette/ isolation room per hospital policy placing the infant in an isolette allows close observation of the ill neonate &protects other infants from infection

5. maintain neutral thermal environment A neutral thermal environment decreases the metabolic needs of the infant. The ill neonate has difficulty maintaining a stable temp

6. Provide respiratory support (oxyhood) resp. support may be needed during the acute phase of the infection to prevent additional physiological stress

7. Monitor lab results as obtained. Notify care giver/physician of abnormal findings lab results provide information about the pathogen and infants response to illness and treatment

8. monitor infant for hypoglycemia, jaundice, development of thrush, or signs of bleeding Assessments coagulation provide information about the development of complications of infection: hypoglycemia, hyperbilirubenia,opportunistic infections, and coagulation deficits.

9. feed infant as ordered (OGT) Nutritional needs may increase during infection while the infant may feed poorly. OG feedings ensure that nutrient needs are met if the infant is too ill to suck effectively

10. administer IV fluids as ordered(D10IMB IV fluids help maintain fluid balance

11. Administer antibiotics as ordered. antibiotics act to inhibit the growth of bacteria and destruction of bacteria.

The infant will exhibit no signs of infection.After 8 hrs of nursing intervention the infant are Free from further infection.