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    NCP - Risk For Infection

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    Siergs Smith Gervacio
    The nursing care plan is for a 6-day-old newborn female diagnosed with meconium aspiration syndrome who is at risk for infection due to an immature immune system. The plan includes an assessment noting the newborn's history of respiratory distress and IV access. The nursing diagnosis identified is risk for infection. Goals are for the newborn to remain free of infection signs within 8 hours. Interventions focus on monitoring for infection signs, hand hygiene, maintaining IV access, encouraging breastfeeding, and educating family. The theoretical basis discusses newborns' susceptibility to infection and the plan's aim to prevent infection occurrence. Evaluation found the newborn free of infection signs with understood teaching provided to the family.

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    NCP - Risk For Infection

    Uploaded by

    Siergs Smith Gervacio
    7K views3 pages
    The nursing care plan is for a 6-day-old newborn female diagnosed with meconium aspiration syndrome who is at risk for infection due to an immature immune system. The plan includes an assessment noting the newborn's history of respiratory distress and IV access. The nursing diagnosis identified is risk for infection. Goals are for the newborn to remain free of infection signs within 8 hours. Interventions focus on monitoring for infection signs, hand hygiene, maintaining IV access, encouraging breastfeeding, and educating family. The theoretical basis discusses newborns' susceptibility to infection and the plan's aim to prevent infection occurrence. Evaluation found the newborn free of infection signs with understood teaching provided to the family.

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    NCP - Risk for Infection

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    The nursing care plan is for a 6-day-old newborn female diagnosed with meconium aspiration syndrome who is at risk for infection due to an immature immune system. The plan includes an assessment noting the newborn's history of respiratory distress and IV access. The nursing diagnosis identified is risk for infection. Goals are for the newborn to remain free of infection signs within 8 hours. Interventions focus on monitoring for infection signs, hand hygiene, maintaining IV access, encouraging breastfeeding, and educating family. The theoretical basis discusses newborns' susceptibility to infection and the plan's aim to prevent infection occurrence. Evaluation found the newborn free of infection signs with understood teaching provided to the family.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    7K views3 pages

    NCP - Risk For Infection

    Uploaded by

    Siergs Smith Gervacio
    The nursing care plan is for a 6-day-old newborn female diagnosed with meconium aspiration syndrome who is at risk for infection due to an immature immune system. The plan includes an assessment noting the newborn's history of respiratory distress and IV access. The nursing diagnosis identified is risk for infection. Goals are for the newborn to remain free of infection signs within 8 hours. Interventions focus on monitoring for infection signs, hand hygiene, maintaining IV access, encouraging breastfeeding, and educating family. The theoretical basis discusses newborns' susceptibility to infection and the plan's aim to prevent infection occurrence. Evaluation found the newborn free of infection signs with understood teaching provided to the family.

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    of 3

    RLE 002

    Cebu Normal University


    College of Nursing
    Cebu City
    Mission-Vision: Care Using Knowledge and Compassion
    Theory-based (Betty Neuman)

    NURSING CARE PLAN


    Assessment
    Diagnosis

    3 points
    3 points

    Goals
    Theoretical Basis

    2 points
    2 points

    Interventions
    Evaluation

    4 points
    1 point

    Bibliography
    15 points

    Name of Student:
    Gervacio, Siergs Smith
    Clients Initials: Baby Girl G.
    Stressor Classification: (Please check)
    Age: 6 days old Gender: Female Civil Status: Newborn Religion: Catholic
    ___*__ Physiological (body structure and functions)
    Allergies: None
    ___x__ Psychological (mental processes and emotion)
    Diet: Breast milk
    ___x__ Socio-cultural (relationships, social expectations)
    Date of Admission: January 22, 2015
    ___x__ Spiritual (influence of spiritual beliefs)
    Diagnosis/Impression: Meconium Aspiration Syndrome
    ___x__ Developmental (developmental processes over the lifespan)

    NURSING DIAGNOSIS
    Assessment
    Subjective:
    Ganahan naman mi
    mu-uli sir kay kung
    madugay mi diri basin
    magkasakit nasad ni
    akong anak.
    As verbalized by the
    patients mother.

    Diagnosis

    NURSING GOALS

    Interventions

    (Goal attainable within the


    shift)

    (with Rationale & Source)

    Actual Evaluation

    Within our care (8


    PRIMARY INTERVENTIONS
    hours), the newborn will: Promotive: Source : Nursess Pocket Guide p. 468
    -471

    Risk for infection r/t


    immature immune
    system

    Objective:
    6 days old.
    6th day hospital
    stay.

    NURSING OUTCOME

    Mutual Planning

    Manifest no signs
    of infection like
    fever and chills
    Vital Signs within
    normal range
    Normal breath
    sounds
    No reports of
    increased
    weakness or
    fatigue
    SO will verbalize
    understanding of
    individual

    Monitor Vital Signs


    R To determine any abnormal changes,
    raise in temperature may indicate
    infection.
    Note risk factors for occurrence of
    infection (Immunocompromised host,
    sharing close quarters with other
    patients, prolonged hospitalization)
    R To assess causative/contributing
    factors
    Assess nutritional status, including
    weight.
    R - Patients with poor nutritional status
    may be anergic, or unable to muster a
    cellular immune response to pathogens
    and are therefore more susceptible to
    infection.

    Vital signs
    remained within
    normal range
    Temp = 36.4C
    PR = 139 BPM
    RR = 58 CPM
    NB has normal
    breath sounds
    Absence of
    heat, pain,
    redness,
    swelling, and
    unusual
    drainage in any
    area
    Newborn is free

    Sharing close
    quarters with
    other patients.
    History of
    respiratory
    distress
    IV line of #4
    D5IMB 500 cc @
    11-12 cc/hr
    infusing well on R
    arm.
    Baseline Vital
    signs of:
    T = 36.6 C
    PR = 144 BPM
    RR = 44 CPM

    Theoretical basis:
    The vast majority of newborns
    enter the world healthy. But
    sometimes, infants develop
    conditions that require medical
    tests and treatment.
    Newborns are particularly
    susceptible to certain diseases,
    much more so than older
    children and adults. Their new
    immune systems aren't
    adequately developed to fight
    the bacteria, viruses, and
    parasites that cause these
    infections.
    As a result, when newborns
    get sick, they may need to
    spend time in the hospital to
    recover. Thats why I have
    come up to a diagnosis of risk
    for infection because of the
    newborns immature system
    and formulated a plan of care
    proper for the newborn.

    causative risk
    Preventive: Source : Nursess Pocket Guide p.
    468 -471
    factors
    Wash hands before and after providing
    SO will identify
    care to the patient
    interventions to
    R Hand washing is the single best way to
    prevent or reduce
    avoid spreading of pathogen

    Anchor IV tubings.
    risk of infection
    R - in order to reduce trauma to the tissues
    SO will
    and the risk for introduction of pathogens
    demonstrate
    associated with the in-and-out movement
    techniques,
    of the tubing
    lifestyle changes
    Instruct and assist client to perform
    good perineal care routinely and after
    to promote safe

    every bowel movement.


    environment
    R Proper perineal care reduces risk for
    Demonstrates
    infection. Teach front to back wiping
    appropriate
    maneuver.
    hygienic measures SECONDARY INTERVENTIONS
    such as hand
    Curative Source : Nursess Pocket Guide p. 468 -471
    washing.
    Administer/monitor medication

    regimen and note patients response.


    R To determine effectiveness of therapy
    or presence of side effects
    Encourage mother to breastfeed every
    2 hours and teach mother the
    importance of breastfeeding.
    R - Colostrum and breast milk contain high
    amounts of immunoglobulin A, which
    provides passive immunity and helps
    reduce infection

    TERTIARY INTERVENTIONS
    Rehabilitative
    Source : Nursess Pocket Guide p. 468 -471

    Source:
    http://kidshealth.org/parent/infection
    s/
    common/neonatal_infections.html

    Instruct SOs in techniques to protect


    the integrity of skin, care for lesions,
    and prevention of spread of infections
    R To avoid infection to the
    immunocompromised.
    Teach patient and caregiver the signs
    and symptoms of infection, and when
    to report these to the physician or
    nurse.
    R to allow early and prompt treatment
    Teach mother childhood immunization
    program (EPI).
    R Immunization reduces risks of
    acquiring diseases.

    of signs and
    symptoms of
    infection such
    as fever and
    fatigue.
    Mother had fully
    understood the
    importance of
    breast feeding
    in relation to
    strengthening
    the immunity
    Demonstrates
    appropriate
    hygienic
    measures and
    verbalized its
    importance
    SOs
    demonstrate
    appropriate care
    of infectionprone site (IV
    site)

    Bibliography:

    Doenges, et al., (2010) Nurses Pocket Guide 12 th edition. F.A Davis Company, Philadelphia.
    Kamis (2013). Risk for infection. [ONLINE] Available at: http://nursinginterventionsrationales.blogspot.com/2013/07/risk-for-infection.html. [Last Accessed 28
    January 2015].
    Audrey Klopp (2012). Infection, Risk for Universal Precautions; Standard Precautions; CDC Guidelines; OSHA. [ONLINE] Available at:
    http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick33.html. [Last Accessed 28 January 2015].

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