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Nursing Problem/Cues Risk for Injury related to prematurity and sepsis. S> - Patient was born at home by midwife.

- Sa bahay lang ako nanganak. - Mother verbalized that the patient was expected to be born in August. -Hindi siya masyadong dumidede kasi madalas siyang tulog. - Grandmother verbalized the patient not receiving Vitamin K after birth. O> -yellowish discoloration of skin. -poor sucking reflex -green stool, twice a day with urine; 3 oz. each -use of bililight 12 hours/day since

Analysis Preterm infants are highly susceptible to early sepsis and pneumonia with RDS, since preterm delivery has been increasingly shown to be associated with a maternal bacterial pathogen. ELBW and VLBW infants are also high susceptible to fungal and viral infections. Because the infants poor response to pathogenic agents, there is usually no local inflammatory reaction at the portal of entry to signal an infection. Sepsis refers to a generalized bacterial infection in the bloodstream. Sepsis can be acquired prenatally across the placenta from the maternal bloodstream or during labor from ingestion or aspiration of infected amniotic

NURSING CARE PLAN Goal/Objectives Nursing Interventions After 1 week of nursing intervention, the patient will be free of injury. a. After 30 minutes of discussion, the parents of the patient will be able to state newborn care, including jaundice in less than 10 minutes. 1. Instruct parents regarding newborn care, including jaundicethe appearance, significance, importance of followup visit to practitioner within 2-3 days of discharge, feeding methods, and noting stooling and voiding. 2. Demonstrate newborn care.

Rationale

Evaluation
Effectiveness Were the parents of the patient able to state newborn care, including jaundice in less than 10 minutes? Yes__NO__Why? Were the parents of the patient able to demonstrate newborn care correctly? Yes__No__ Why? Was the patients skin free from injury and damage? Yes__NO__Why?

a. To enhance parentinfant interaction and acquaintance.


Wongs Nursing Care of th Infants and Children, 8 Ed. pg. 324

b. After 1 day of nursing intervention, the parents of the patient will be able to demonstrate newborn care correctly. c. After nursing intervention, the patients skin will be free from injury and damage.

b. To enhance parentinfant interaction and acquaintance.


Wongs Nursing Care of th Infants and Children, 8 Ed. pg. 324

Were the parents of the patient able to provide parental supervision? Yes__No__Why? Were the parents of the patient able to perform safety precautions appropriately? Yes__No__Why? Was the patient able to have vital signs within normal range? Yes__No__Why?

3. Handle infant gently.

c. Skin and tissues are fragile and are at risk for damage. Nursing
Care Plans by Marilynn th E. Doenges, 8 Ed. pg. 899

admission. -weak cry -pale, dry lips -T = 35.8 C (Hypothermic)

fluid. The nonspecific, early signs are hypothermia, poor feeding, diarrhea or decreased stool, and jaundice. An excessive level of accumulated bilirubin in the blood is characterized by jaundice. Unconjugated bilirubin is highly toxic to neurons; therefore an infant with severe jaundice is at risk of developing bilirubin encephalopathy, which may result to Kernicterus. Unconjugated and elevated bilirubin crosses the blood-brain barrier in neonates, causing the infant to have increased permeability of the blood-brain barrier to unconjugated bilirubin and, thus, potential irreversible damage.
Wongs Nursing Care of Infants and Children, 8th Ed Vol.1 pg 321-322

d. After nursing intervention, the parents of the patient will provide parental supervision.

4. Encourage parents of patient to provide appropriate level of supervision, with nurses assistance.

d. Permits monitoring of childs well-being and allows for timely intervention. Nursing
Care Plans by Marilynn th E. Doenges, 8 Ed. pg. 899

Was the patient able to receive appropriate medications? Yes__No__Why? Were the parents of the patient able to

e. After 1 day of nursing intervention, the parents of the patient will be able to perform safety precautions appropriately. f. After 1 day of nursing intervention, the parents of the patient will be able to demonstrate safety needs and injury prevention in home setting. g. After 1 day of nursing intervention, the patient will be able to have vital signs that are within normal range.

5. Initiate safety precautions as individually appropriate, such as infection precaution.

e. Preventing injuries and complications is a prime responsibility of parents and caregivers. Nursing Care
Plans by Marilynn E. Doenges, 8th Ed. pg. 899

demonstrate safety needs and injury prevention in home setting? Yes__No__Why? Were the parents of the patient able to verbalize desire to attend community educational programs? Yes__No__Why?
Efficiency Were resources available to the nurse and client? Yes__No__ Why?

6. Review home situation for safety hazards. Ascertain parent knowledge of safety needs and injury prevention in home setting.

f. Promotes a safe environment. Nursing


Care Plans by Marilynn E. Doenges, 8th Ed. pg. 899

7. Monitor vital signs per unit protocol or at least every 8 hours. Report signs of poor transition to extrauterine life.

g. To promote physical care of newborn and decrease parents anxiety related to home care. Wongs
Nursing Care of Infants and Children, 8th Ed. pg. 324

Appropriateness Were interventions appropriate to client situation? Yes__No__ Why?

h. After nursing intervention, the patient will be able to receive appropriate medications.

8. Monitor medication administration closely, especially dosage measurements and conversions. Use pediatric concentrations of medications when available. 9. Refer to community education programs and resources, such as Family Effectiveness Training.

h. Provides for effective therapeutic management, prevents overdose, and reduces risk for toxic reactions.
Nursing Care Plans by Marilynn E. Doenges, 8th Ed. pg. 899

Acceptability Were all interventions acceptable to the client? Yes__No__ Why? Adequacy Were the numbers of the interventions enough to solve the health problems? Yes__No__ Why?

i. After nursing intervention, the patients parents will be able to verbalize desire to attend community educational programs.

i. Can provide additional opportunities for improving parenting skills and obtaining necessary equipment. Nursing Care Plans by
Marilynn E. Doenges, 8th Ed. pg. 899

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