Neonatal Sepsis NCP

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Fluid volume deficit
Assessment

S

OThe patient may
manifest:
- 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

Nursing
Diagnosis
Fluid volume
deficit related to
failure of
regulatory
mechanism

Scientific
Explanation
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
specifically
hyperthermia

Planning

Intervention

Rationale

Expected
Outcome

1. Monitor and
record vital signs

1. To note for
the alterations in
V/S (decreased
BP, Increased in
PR and temp)

2. Note for the
causative factors
that contribute to
fluid volume
deficit

2. To assess
what factor
contributes to
fluid volume
deficit that may
be given prompt
intervention.

3. Provide TSB if
patient has fever

3. To decrease
temperature and
provide comfort

The patient shall
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 skin turgor
and prompt
capillary refill
and resolution of
edema.

4. Provide oral
care by
moistening lips &
skin care by
providing daily
bath
5. Administer IV
fluid
replacement as
ordered

4. To prevent
injury from
dryness

Short-term:
After 3 hours of
nursing
intervention the
patient will 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 skin turgor
and prompt
capillary refill
and resolution of
edema.
Long Term:
After a couple of
days the patient
will still be able
to maintain fluid
volume at a
functional level

5. replaces fluid
losses

as evidenced by
individually
adequate urinary
output with
normal specific
gravity, stable
vital signs, moist
mucous
membranes,
good skin turgor
and prompt
capillary refill
and resolution of
edema.

6. Administer
antipyretic drugs
if patient has
fever as ordered

6. to reduce
body
temperature

Ineffective Tissue Perfusion
Assessment

S

OThe patient may
manifest one or more
of the following:
- skin or
temperature
changes
- Weak pulses
- Edema
- Inadequate
urine output

Nursing
Diagnosis
Ineffective
tissue
perfusion
related to
impaired
transport of
oxygen across
alveolar and on
capillary
membrane

Scientific
Explanation
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

Planning

Intervention

Rationale

Short-term:

Independent

After 3 hours of
nursing
intervention the
patient will
demonstrate
increased
perfusion as
evidenced by
warm and dry
skin, strong
peripheral
pulses, normal
vital signs,
adequate urine
output and
absence of
edema

1. Monitor
neonate’s
condition.

1. To determine
the need for
intervention and
the
effectiveness of
therapy.

2. Monitor Vital
signs

2. To have a
baseline data

3. Note quality
and strength of
peripheral
pulses

3. To asses
pulse that may
become weak
or thready,
because of
sustained
hypoxemia

Long Term:

4. Assess
respiratory rate,
depth, and
quality

4. To note for
an increased
respiration that
occurs in
response to
direct effects of
endotoxins on
the respiratory
center in the
brain, as well as
developing
hypoxia, stress.

After 3 days of
NI, pt will
maintain
adequate
perfusion AEB
stable VS,
warm and dry
skin, absence
of edema,
adequate urine

Expected
Outcome
The patient
shall
demonstrate
increased
perfusion as
evidenced by
warm and dry
skin, strong
peripheral
pulses, normal
vital signs,
adequate urine
output and
absence of
edema

output and
strong
peripheral
pulses.

Respirations
can become
shallow as
respiratory
insufficiency
develops
creating risk of
acute
respiratory
failure.
5. Assess skin
for changes in
color,
temperature and
moisture

5. To assess for
compensatory
mechanisms of
vasodilation

6. Elevate Head
of Bead

7. Elevate
affected
extremities with
edema once in a
while

6. To promote
circulation
/venous
drainage
7. To reduce
edema

Interdependent
8. Provide a
quiet, restful
atmosphere

8. Conserves
energy and
lowers O2

Dependent
9. Administer
oxygen as
ordered

demand

9. To maximize
O2 availability
for cellular
uptake

Interrupted Breast Feeding
Assessment

S

OThe newborn is
diagnosed with a
certain disease
(Sepsis)
- The newborn is
separated from
his mother
- The mother
unable to
provide breast
milk to newborn
continuously

Nursing
Diagnosis
Interrupted
breastfeeding
related to
neonate’s
present illness
as evidenced by
separation of
mother to infant

Scientific
Explanation
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.

Planning

Intervention

Rationale

1. Assess
mother’s
perception and
knowledge about
breastfeeding
and extent of
instruction that
has been given.

1. To know what
the mother
already knows
and needed to
know.

2. Give
emotional
support to
mother and
accept decision
regarding
cessation/
continuation of
breast feeding.

2. To assist
mother to
maintain
breastfeeding as
desired.

3. Demonstrate
use of manual
piston-type
breast pump.

3. aid in feeding
the neonate with
breast milk
without the
mother
breastfeeding
the infant.
4. To provide
optimal nutrition
and promote
continuation of

Expected
Outcome

Short-term:
After 3 hours of
nursing
intervention and
health teachings
the mother will
identify and
demonstrate
techniques to
sustain lactation
until
breastfeeding is
initiated
Long Term:
After 3 days of
NI, the mother
shall still be able
to identify and
demonstrate
techniques to
sustain lactation
and identify
techniques on
how to provide
the newborn with
breast milk.

4. Review
techniques for
storage/use of
expressed

The mother shall
be able to
identify and
demonstrate
techniques to
sustain lactation
and identify
techniques on
how to provide
the newborn with
breast milk.

breast milk

breastfeeding
process

5. Determine if
5. So that infant
a routine visiting will be hungry/
schedule or
ready to feed
advance warning
can be provided
6. Provide
privacy, calm
surroundings
when mother
breast feeds.

6. To promote
successful infant
feeding

7. Recommend
for infant sucking
on a regular
basis

7. Reinforces
that feeding time
is pleasurable
and enhances
digestion.

8. Encourage
mother to obtain
adequate rest,
maintain fluid and
nutritional intake,
and schedule
breast pumping
every 3 hours
while awake

8. to sustain
adequate milk
production and
breast feeding
process

Risk for impaired parent/ infant attachment
Assessment

S

OThe newborn is
diagnosed with a
certain disease
(Sepsis)
- the newborn is
hospitalized
- The newborn is
separated from
his parents

Nursing
Diagnosis
Risk for Impaired
parent/ neonates
Attachment
related to
neonates
physical illness
and
hospitalization.

Scientific
Explanation
Due to the
newborn’s
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.

Planning

Intervention

Rationale

Expected
Outcome

1. Interview
parents, noting
their perception
of situation and
individual
concerns

1. To know what
the parents
feelings about
the situation.

the parents shall
be able to have
a mutually
satisfying
interactions with
their newborn.

2. Educate
parents
regarding child
growth and
development,
addressing
parental
perceptions

2. Helps clarify
realistic
expectations

Short-term:
After 3 hours of
nursing
intervention and
health teachings
the mother will
identify and
demonstrate
techniques to
enhance
behavioral
organization of
the neonate
Long Term:
After discharge
the parents will
be able to have
a mutually
satisfying
interactions with
their newborn.

3. Involve
3. Enhances
parents in
self-concept
activities with the
newborn that
they can
accomplish
successfully

4. Recognize
and provide
positive
feedback for

4. Reinforces
continuation of
desired
behaviors

nurturant and
protective
parenting
behaviors

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