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Due to the presence of an infectious agents, stimulation of the monocytes triggers the release of the pyrogenic cytokines that

stimulate anterior hypothalamus which results in elevated thermoregulatory set point that leads to an increased heat conservation (Vasoconstriction) and increased heat production which results to fever.

Assessment Subjective: May manifest:  Irritability  Weakness Objective: The patient may manifest one or more of the following:
  

Temperature above normal level (36 oC) Skin warm to touch Presence of tachycardia (above 160 bpm) Presence of tachypnea (above 60 bpm) WBC elevated

Nursing Diagnosis Planning Intervention Hyperthermiarelated Short-term:After 30 Independent1. to inflammatory minutes Monitor neonates process/ ofnursinginterventionthe condition. hypermetabolic patient will maintain 2. Monitor Vital state as evidenced normal core temperature signs by an increase in as evidenced by vital body temperature, signs within normal warm skin and limits and normal WBC 3. Provide TSB tachycardia level Interdependent Long Term: 4. Ensure that After 3 days of NI, pt allequipment will still maintain usedfor infant is normal core temperature sterile, as evidenced by normal scrupulously vital signs and clean. Do not normallaboratoryresults. share equipment with other infants Dependent

Rationale Expected Outcome 1. To determine The patient shall the need maintain normal core forinterventionand temperature as the effectiveness evidenced by normal of therapy.2. To vital signs and have a baseline normallaboratoryresults. data 3. Helps in lowering down the temperature 4. this would prevent the spread of pathogens to the infant from equipment 5. aids in lowering down temperature

5. Administer Anti-pyretics as

ordered
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2 Fluid Volume Deficit


Fluid volume deficit, or hypovolemia, occurs from a loss of body fluid or the shift of fluids into the third space one factor includes a failure of the regulatory mechanism of the newborn specificallyhyperthermia

Assessment

Nursing Diagnosis

Planning

Intervention

Rationale

Expected Outcome

Fluid volume deficit related to The patient may manifest failure of one or more of the regulatory following: mechanism Subjective:Objective:
   

  

decreased urine output increased urine concentration increased pulse rate (above 160 bpm) increased body temperature (above 36 oC) decreased skin turgor dry skin/ mucous membranes elevated hct

Short-term:After 3 1. Monitor and 1. To note for the The patient shall hours record vital alterations in V/S be able to ofnursinginterventionthe signs2. Note for (decreased BP, maintain fluid patient will be able to the causative Increased in PR volume at a and temp)2. To functional level as maintain fluid volume at factors that a functional level as contribute tofluid assess what factor evidenced by evidenced by contributes tofluid individually volume deficit volume deficit that adequate urinary individually adequate 3. Provide TSB if output with urinary output with may be given patient has fever normal specific gravity, promptintervention. normal specific stable vital signs, moist gravity, stable 3. To decrease 4. Provide oral mucous vital signs, moist care by moistening temperature and membranes,good mucous provide comfort skinturgor and prompt lips & skin care by membranes,good providing daily capillary refill and skinturgor and bath 4. To prevent resolution of edema. prompt capillary injury from dryness refill and Long Term: 5. Administer IV resolution of fluid replacement 5. replaces fluid edema. After a couple of days

the patient will still be able to maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes,good skinturgor and prompt capillary refill and resolution of edema.

as ordered

losses

6. Administer 6. to reduce body antipyretic drugs if temperature patient has fever as ordered

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3 Ineffective Tissue Perfusion


Since the body of the newborn is unable to compensate to the imbalances of the inflammatory response related to his condition the body tends to hyperdrive causing an inadequate oxygen in the tissues or capillary membrane leading to poor perfusion.

Nursing Diagnosis Subjective:Objective: Ineffective tissue perfusionrelated The patient may manifest to impaired one or more of the transport of following: oxygen across alveolar and on  skin or temperature capillary changes membrane  Weak pulses

Assessment

Expected Outcome Short-term:After 3 Independent 1. To determine the need The patient shall hours forinterventionand the demonstrate 1. Monitor neonates ofnursinginterventionthe increased effectiveness of condition. patient will demonstrate perfusion as therapy.2. To have a increased perfusion as evidenced by baseline data 2. Monitor Vital evidenced by warm warm and dry 3. To asses pulse that signs and dry skin, strong skin, strong may become weak or peripheral pulses, peripheral 3. Note quality and thready, because of normal vital signs, pulses, normal

Planning

Intervention

Rationale

 

Edema Inadequate urine output

adequate urine output and absence of edema

strength of peripheral sustained hypoxemia vital signs, pulses adequate urine output and 4. To note for an Long Term: increased respiration that absence of 4. edema Assessrespiratory rate, occurs in response to depth, and quality direct effects of endotoxins on After 3 days of NI, pt the respiratorycenter in 5. Assess skin for will maintain adequate the brain, as well as changes in color, perfusion AEB stable developing hypoxia, temperature and VS, warm and dry skin, moisture stress. Respirations can absence of edema, become shallow adequate urine output asrespiratoryinsufficiency 6. Elevate Head of and strong peripheral develops creating risk of Bead pulses. acuterespiratoryfailure. 7. Elevate affected 5. To assess for extremities with edema once in a while compensatory mechanisms of vasodilation Interdependent 8. Provide a quiet, restful atmosphere Dependent 6. To promote circulation /venous drainage 7. To reduce edema 8. Conserves energy and lowers O2demand 9. Administer oxygen 9. To maximize as ordered O2 availability for cellular uptake

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4 Interrupted Breastfeeding
Since the neonate is diagnosed for having a neonatal sepsis, the baby got separated from his mother and placed on a Neonatal Intensive Care Unit for better management and care. Interrupted breastfeeding develops since the mother is unable to breast fed the baby continuously due to their separation.

Expected Outcome Subjective:Objective: Interrupted Short-term:After 3 1. Assess 1. To know what The mother shall breastfeedingrelated hours mothers the mother already be able to identify The patient may manifest to neonates present ofnursinginterventionand perception and knows and needed and demonstrate one or more of the illness as evidenced health teachings the knowledge about to know.2. To techniques to following: by separation of sustain lactation mother will identify and breastfeeding and assist mother to mother to infant and identify demonstrate techniques extent of maintain  The newborn is techniques on to sustain lactation until instruction that has breastfeeding as diagnosed with a how to provide breastfeeding is initiated been given. desired. certain disease the newborn with Long Term: 2. Give emotional 3. aid in feeding (Sepsis) breast milk. support to mother the neonate with  The newborn is and accept breast milk without separated from his decision regarding the mother mother breastfeeding the  The mother unable to After 3 days of NI, the cessation/ infant. continuation of provide breast milk mother shall still be able breast feeding. to newborn to identify and continuously 4. To provide demonstrate techniques to sustain lactation and 3. Demonstrate optimalnutrition and promote identify techniques on use of manual piston-type breast continuation of how to provide the pump. breastfeeding newborn with breast process 4. Review

Assessment

Nursing Diagnosis Planning

Intervention

Rationale

milk.

techniques for storage/use of expressed breast milk 5. Determine if a routine visiting schedule or advance warning can be provided

5. So that infant will be hungry/ ready to feed 6. To promote successful infant feeding 7. Reinforces that feeding time is pleasurable and enhancesdigestion.

6. Provide privacy, calm surroundings when 8. to sustain mother breast adequate milk feeds. production and breast feeding 7. Recommend process for infant sucking on a regular basis 8. Encourage mother to obtain adequate rest, maintain fluid and nutritional intake, and schedule breast pumping every 3 hours while awake
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5 Risk for Impaired Parent/Infant Attachment


Due to the newborns physical illness and hospitalization, the parents may have fear on how to handle their baby since the baby is on its fragile state and needed extra care. And since he is the 1st child hospitalized in their family, the parents might still be unsure on how to take care of the baby.

Nursing Planning Intervention Diagnosis Subjective:Objective: Risk for Impaired Short-term:After 3 1. Interview parent/ neonates hours of parents, noting The patient may manifest Attachment nursinginterventionand their perception of one or more of the related to neonates health teachings the situation and following: physical illness mother will identify individual and and demonstrate concerns2.  The newborn is hospitalization. techniques to enhance Educate parents diagnosed with a behavioral regarding child certain disease organization of the growth and (Sepsis) neonate development,  The newborn is addressing Long Term: separated from his parental mother perceptions  The mother unable to 3. Involve parents provide breast milk in activities with to newborn After discharge the continuously parents will be able to the newborn that they can have a mutually satisfying interactions accomplish successfully with their newborn. 4. Recognize and provide positive feedback for

Assessment

Expected Outcome 1. To know what the parents shall the parents be able to have a feelings about the mutually situation.2. Helps satisfying clarify realistic interactions with expectations their newborn. 3. Enhances selfconcept 4. Reinforces continuation of desired behaviors

Rationale

nurturant and protective parenting behaviors