VI.

NURSING MANAGEMENT

Nursing Care Plan Problem #1: Risk for Infection

Cues Nursing Scientific Objectives Nursing Rationale Evaluation

Diagnosis Explanation Interventions

S:  Risk for The patient is at After 1 hour of Monitor v/s and For baseline data Were the vital signs
O: pt. may infection r/t risk of acquiring nursing assess patient’s stable?
manifest: impaired infection due to interventions, the condition
primary the break in the patient will
Observe and With the onset of Are there any
> Invasive defense. continuity of the demonstrate
report signs of infection the immune changes skin color
procedures first line defense techniques in infection such as system is activated discolorations and
(amniocentesis which is the skin. reducing risk of redness, warmth, and signs of infection body temperature?
or intrauterine The patient shall having infection discharge, and appear.
blood transfusion have undergone increased body
amniocentesis or temperature.
>Insufficient intrauterine
knowledge to blood Stress the A first line defense Did the client
avoid exposure transfusion thus importance of against nosocomial understand the
there is an proper hand infection or cross handwashing
to pathogen
washing contamination technique
incision and
properly??
> inadequate suture made in Strict compliance To establish
secondary the abdomen. If to hospital control, mechanism to Is SOP for hospital
defenses (e.g., there is a sterilization, and prevent occurrence of sterilization properly
decreased breakage in the aseptic policies infection monitored?
hemoglobin, skin, the
leukopenia, pathogens will Are there any side
suppressed easily invade the Tell patient to To prevent the effects to the
inflammatory body’s system comply to occurrence of antibiotic treatment?
thus increasing antibiotic therapy infection
response); as prophylaxis Did the patient
risk for infection
follow the
> rupture of Monitor To determine prescribed
amniotic medication effectiveness of medications?
membranes regimen therapy
Problem #2: Risk for Fluid Volume Deficit related to Phototherapy

Cues Nursing Scientific Objectives Nursing Rationale Evaluation

Diagnosis Explanation Interventions

OBJECTIVE: Risk for fluid Phototherapy The infant will > Initiate early > To increase >Was early feeding
Clinical volume deficit enhances the exhibit no signs feedings and offer intestinal motility initiated?
jaundice related to excretion of of dehydration, feedings ever 2-3 and promote the
evident within phototherapy unconjugated clear amber hours excretion of
unconjugated
24 hour of birth bilirubin through urine output of
bilirubin through the
the bowel. 1-3 mL/kg/hr, clearance of stools
and will display and to decrease the
appropriate potential for
weight gain. dehydration

> Monitor urine > Urine specific >What was the

specific gravity gravity can be an urine’s specific
indicator of gravity?
dehydration.
Dehydration and
fluid volume deficit
will show an
elevation in the
urine specific gravity

>Administer fluid > Additional fluids >Was fluid loss

intake that is 25% will help
compensated?
above normal compensate for the
requirements increased water that
is lost through the
skin and in the
stools

>Were the
> Assess for signs > Phototherapy fontanels’ sunken?
of dehydrations treatment may What was the skin
such as poor skin cause liquid stools turgor?
turgor, depressed and increased
fontanels, sunken insensible water
eyes, decreased loss, which
urine output, increases risk of
weight loss, and dehydration.
changes in
electrolytes

> Monitor daily >Increased fluid >Was there an

weight. excretion in the increase on the
stools and a daily weight?
decrease in fluid
intake may put the
newborn at risk for
weight loss. Daily
weights can provide
accurate
determination fluid
intake and
insensible water
loss that is caused
by phototherapy

> Assess quantity > Loose stools >What was the

and characteristics indicate fluid loss characteristic of
of each stool. which may lead to a the stool?
fluid volume deficit.
With an increase in
stools per day,
dehydration is
possible.