NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION

INDEPENDENT: SUBJECTIVE: Walang gana dumede ang anak ko, parang mainit sya at matamlay as verbalized by the mother. OBJECTIVE: Increase body temperature. Flushed skin. Increase respiratory rate. V/S taken as follows: Risk for infection related to compromised immune system. Sepsis is a clinical term used to describe symptomatic bacteremia, with or without organ dysfunction. Sustained bacteremia, in contrast to transient bacteremia, may result in a febrile response that may be associated with organ dysfunction. Septicemia refers to the active multiplication of bacteria in the bloodstream those results in an overwhelming infection. After 4 hours of nursing interventions, the patient will achieve timely healing and free from further infection.

RATIONALE

EVALUA

Provide isolation and monitor visitors as indicated.

Body substance isolation should be used for all infectious patients. Reverse isolation restriction of visitors may be needed to protect the immune suppresed patient.

After 4 hou nursing intervention patient was to achieve t healing and from furthe infection.

T: 37.7 CR: 130 R: 45

Wash hands before or after each care activity, even when gloves are used.

Reduces the risk of cross contamination, because gloves may have noticeable defects, get torn or damaged during use.

Limit use of invasive devices or procedure as possible

Prevents spread of infection via airborne droplets.

Provide tepid sponge bath.

Used to reduce

Monitor signs

of deterioration of condition or failure to improve in therapy.

May reflect in appropriate antibiotic therapy or over growth of secondary infections.

COLLABORATIVE:

Obtain specimens of urine, blood, sputum, as indicated for gram stain and sensitivity.

Identification of portal entry and organisms causing the septicemia is crucial in effective treatment.

Administer antibiotics as prescribed.

To prevent further spread of infection.

DISCHARGE PLANNING
a. General Condition of Client upon Discharge Baby Boy Villegas, one day prior to discharge, is active and afebrile. He already demands for his feedings and has good suck and well-tolerated feedings. He is also not ill-looking unlike before. He is well flexed, with full range of motion and with spontaneous movement. His overall health condition is generally good. The doctor instructed the mother for continuation of antibiotics and to return for follow-up checkup at OPD

b. METHOD

-MEDICATION -Amikacin 38mg. IV OD (10am) -Gentamicin 15mg IV OD (9am) -EXERCISE -stressed that the baby sleeps more often times - TREATMENT -stressed importance of complying with the medications and follow-up checkup. -HEALTH TEACHINGS -instructed the mother to bring back the baby for checkup -instructed the mother all the medication that will be given or thats been given including Its natural side effects. -instructed the mother the importance of breast feeding -instructed the mother on proper breastfeeding -instructed the mother to expose the baby to sunlight at 6am to 10am only -instructed the mother about the diet of the baby -instructed the mother to burped the baby after each feedings

-DIET -instructed the mother to feed the baby as tolerated with strict aspiration precaution.