NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

INDEPENDENT:
SUBJECTIVE: Risk for ♦ Sepsis is a ♦ After 8 hours ♦ Provide isolation ♦ Body substance ♦ After 8 hours of
infection related clinical term of nursing and monitor visitors isolation (BSI) nursing
“Walang gana to compromised used to interventions, as indicated. should be used for interventions,
dumede ang anak immune describe the patient all infectious the patient was
ko, parang mainit system. symptomatic will achieve patients. Reverse able to achieve
sya at hindi bacteremia (the timely healing isolation/restriction timely healing
nagkikilos. (“It’s presence of and free from of visitors may be and free from
difficult to feed my bacteria in the further needed to protect further
baby, she feels warm infection. the infection.
to touch and not very blood), with or
without organ immunosuppressed
active”) as
dysfunction. patient.
verbalized by the
mother. Sustained
bacteremia, in ♦ Wash hands before ♦ Reduces risk of
contrast to or after each care cross
OBJECTIVE:
transient activity, even gloves contamination
bacteremia, are used. because gloves
♦ Increased
may result in a may have
body
sustained noticeable defects,
temperature.
febrile response get torn or
♦ Flushed skin.
that may be damaged during
♦ Increased
associated with use.
respiratory
rate. organ
dysfunction. ♦ Limit use of invasive ♦ Prevents spread of
♦ V/S taken as
Septicemia devices or infection via
follows:
refers to the procedure as airborne droplets.
active possible.
T: 37.8°C
P: 130 multiplication of
bacteria in the ♦ Inspect wounds or ♦ May provide clue
R: 45
bloodstream site of invasive to portal entry,
that results in devices, paying type of primary
an particular attention infecting
overwhelming to parenteral lines. organisms, as well
infection. as early
identification
secondary
infection.
♦ Maintain sterile ♦ Prevents
technique when introduction of
changing dressings, bacteria, reducing
suctioning or risk of nosocomial
providing site care. infection.

♦ Provide tepid ♦ Used to reduce

sponge bath and fever.
avoid use of alcohol.

♦ Observe for chills ♦ Chills often

and profuse precede
diaphoresis. temperature spikes
in presence of
generalized
infection.

♦ Monitor for signs of ♦ May reflect

deterioration of inappropriate
condition or failure antibiotic therapy
to improve in or overgrowth of
therapy. secondary
infections.

COLLABORATIVE:
♦ Obtain specimens of ♦ Identification of
urine, blood, portal entry and
sputum, wound as organism causing
indicated for gram the septicemia is
stain, and crucial in effective
sensitivity. treatment.

♦ To prevent further
♦ Administer anti- spread of infection.
biotics as
prescribed.