Student Nurses Community

ASSESSMEN
T

DIAGNOSIS

INFERENCE

NURSING CARE PLAN Neonatal Sepsis

PLANNING

INTERVENTION

RATIONALE

EVALUATI
ON

Body
substance
isolation (BSI)
should be used
for all
infectious
patients.
Reverse
isolation/restric
ti on of visitors
may be needed
to protect the
immunosuppre
ssed patient.
Reduces risk of
cross
contamination
because gloves
may have
noticeable
defects, get
torn or
damaged
during use.
Prevents
spread of

After 8
hours of
nursing
interventio
ns,
the patient
was
able to
achieve
timely
healing
and free
from
further
infection.

SUBJECTIVE:
Walng gana
dumede ang
anak ko,
parang mainit
sya at
matamlay
(its difficult to
feed my baby,
she feels
warm to touch
& not very
active) as
verbalized by
the mother.
OBJECTIVE:
Increased
body
temperature.
Flushed
skin.
Increased
respiratory
rate.

Risk for
infection
related
to
compromise
d
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
sustained
febrile
response that
may
be associated
with
organ
dysfunction.
Septicemia
refers to

After 8 hours INDEPENDENT:

of
Provide isolation
nursing
and monitor
intervention
visitors as
s,
indicated.
the patient Wash hands
will
before or after
achieve
each care
timely
activity, even
healing and
gloves are
free
used.
from further Limit use of
infection.
invasive
devices or
procedure as
possible.
Inspect wounds
or site of
invasive
devices, paying
particular
attention to
parenteral lines.
Maintain sterile
technique when
changing

Student Nurses Community

V/S taken as
follows:
T: 37.7
P: 130
R: 45

the active
multiplication
of
bacteria in the
bloodstream
that
results in an
overwhelming
infection.

dressings,
suctioning or
providing site
care.
Provide tepid
sponge bath
and avoid use
of alcohol.
Observe for chills
and profuse
diaphoresis.
Monitor for signs
of deterioration
of condition or
failure to
improve in
therapy.
COLLABORATIVE:
Obtain specimens
of urine, blood,
sputum, wound
as indicated for
gram stain, and
sensitivity.
Administer
antibiotics as
prescribed.

infection via
airborne
droplets.
May provide
clue to portal
entry, type of
primary
infecting
organisms, as
well as early
identification
secondary
infection.
Prevents
introduction of
bacteria,
reducing risk of
nosocomial
infection.
Used to reduce
fever.
Chills often
precede
temperature
spikes in
presence of
generalized
infection.
May reflect
inappropriate
antibiotic

Student Nurses Community

therapy or
overgrowth of
secondary
infections.
Identification
of portal entry
and organism
causing the
septicemia is
crucial in
effective
treatment.
To prevent
further spread
of infection.