HOLY ANGEL UNIVERSITY
School of Nursing and Allied Medical Sciences
Second Semester, 2021-2022
Nursing Care Management 109
Care of Mother, Child at Risk or with Problems (Acute and Chronic)
NURSING CARE PLAN
Name of Student: Ocampo, Kiana Shane R.
Section: NU-202 Date: February 28, 2022
Patient/Diagnosis: Baby B – Risk for Infection
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective: Risk for Infection related According to Lamont in 2015, Short Term: Independent: Goal met: Client’s
to prematurity, immature the risk of a newborn acquiring After 1 hour of nursing 1. For dressing Aseptic method mother and significant
Objective: immune system, infections rises as the interventions and health changes, reduces the risk of others verbalize
- 5 hours old immature respiratory gestational age and birth weight teachings, client’s mother intravenous pathogens being understanding of the
- 35 weeks system, and invasive decrease. They are most at risk and significant others will therapy, and transmitted to or risk factors of infection
gestation procedure as manifested of infections related to the be able to verbalize catheter spread between and identify 3 risk
- T: 36C by gestation of 35 weeks, respiratory system and neonatal understanding of risk handling, patients. factors.
- HR: 133bpm low birth weight, nasal sepsis. The newborn’s nasal factors of infection and maintain strict Interrupting the
- RR: 42 cpm flaring, hypoxia, grade 1 flaring, hypoxia, and respiratory identify 3 risk factors. asepsis. infection chain is a Client’s mother and
- SBP: 68 mmHg respiratory retractions, retractions indicate an good strategy to significant others are
- SpO2: 86% and intravenous therapy. immature pulmonary After 3 hours of nursing stop infection from able identify 3
- Weight: 2.2 kg functioning because of interventions and health spreading. interventions to
- Good cry upon inadequate lung surfactant. teachings, client’s mother prevent or reduce risk
stimulation This, including an immature and significant others will of infection.
- Nasal flaring immune system, make the be able to identify 3 2. Ensure that any This reduces or
- Grade 1 newborn more at risk for interventions to prevent items used are eliminates germs. Client is free from
respiratory pneumonia and other or reduce risk of properly infections such as
retractions respiratory infections. infection. disinfected or pneumonia, sepsis, and
- Ongoing #1 PNSS Moreover, neonatal sepsis is a sterilized meningitis. Client is also
500ml @ 450ml risk because bacteria and other Long Term: before use. free of purulent
level regulated microorganisms that live in the After 1 month of nursing drainage and erythema.
@ 0.8ml/hr via skin may enter the bloodstream interventions, client will 3. Perform hand Microorganisms are
Lt basilic vein through the vascular catheter be free from infections hygiene before effectively removed Goal partially met:
(IVF of PNSS) placed in the such as pneumonia, having contact from hands using Client’s mother and
HOLY ANGEL UNIVERSITY
School of Nursing and Allied Medical Sciences
Second Semester, 2021-2022
Nursing Care Management 109
Care of Mother, Child at Risk or with Problems (Acute and Chronic)
NURSING CARE PLAN
preterm newborn. sepsis, and meningitis. with the friction and running significant others
Client will also be free of patient. water. Between verbalize understanding
purulent drainage and Provide health procedures, of the risk factors of
erythema. teachings to washing minimizes infection and identify
mother and the chance of only 1 risk factor.
significant infections spreading
others to from one part of the Client’s mother and
perform hand body to another. significant others
hygiene before identify only 1
and after intervention to prevent
touching the or reduce risk of
patient and infection.
their
surroundings. Client is free from
infections such as
4. Provide health Knowledge of the pneumonia, sepsis, and
teachings to risk factors of meningitis. Client is also
mother and infection will allow free of purulent
significant the client’s mother drainage and erythema.
others about and significant
the risk factors others to avoid Goal not met: Client’s
of infection. these risks and mother and significant
perform others are unable to
precautions. verbalize understanding
of the risk factors of
5. Limit visitors. Restricting visitation infection and unable to
reduces the identify any risk factors.
transmission of
pathogens. Client’s mother and
significant others are
Dependent: unable to identify any
HOLY ANGEL UNIVERSITY
School of Nursing and Allied Medical Sciences
Second Semester, 2021-2022
Nursing Care Management 109
Care of Mother, Child at Risk or with Problems (Acute and Chronic)
NURSING CARE PLAN
1. Increase fluid Fluids aid in the interventions to
intake with IV production of prevent or reduce risk
therapy. diluted urine, of infection.
frequent bladder
emptying, and the Client develops
reduction of urine infections such as
stasis. As a result, pneumonia, sepsis, and
the risk of bladder meningitis.
infection is reduced.
2. Initiate lung Lung surfactant
surfactant therapy lowers the
therapy. incidence of
pulmonary air leak
that may result to
infections and
lowers the risk of
chronic lung illness
in preterm infants.
HOLY ANGEL UNIVERSITY
School of Nursing and Allied Medical Sciences
Second Semester, 2021-2022
Nursing Care Management 109
Care of Mother, Child at Risk or with Problems (Acute and Chronic)
NURSING CARE PLAN
References:
Lamont, R.F. (2015). Advances in the Prevention of Infection-Related Preterm Birth. Retrieved from https://doi.org/10.3389/fimmu.2015.00566
Steiner L. (2019). Risk of infection in the first year of life in preterm children: An Austrian observational study. Retrieved from https://doi.org/10.1371/journal.pone.0224766
