TONDO MEDICAL CENTER- PEDIA WARD

Nursing Care Plan

Patient: Baby A- 8 days old (Current dx: Sepsis)
Assessment
Subjective Data:
Patient is incapable
of verbal
communication.
Mother verbalized
Mainit ang anak
ko.
Objective Data:
Body temperature
above normal
range (38.3C,
axillary)
Tachypnea (73
breaths/min)
Tachycardia (160
beats/min)
Warm, flushed skin
Facial grimacing,
crying

Date of Confinement: September 17, 2009

Nursing
Diagnosis

Inference

Hyperthermia
related to
inflammatory
process
secondary to
disease process
as manifested by
increased
temperature

Sepsis

Goal

Intervention

Rationale

Evaluation

After 2 hours of
1.Establish rapport with 1.Establishing rapport
After 2 hours of
effective
nursing
the
patient
and
promotes
patient
effective nursing

intervention,
the
guardian.
and
guardians
intervention, the
Pooling of bacteria in
patients
cooperation
in
the
patients
the blood stream
temperature will
nursing care.
temperature

return to normal as
returned to normal
Inflammatory
manifested by:
2.Monitor temperature. 2.Monitoring helps the
as manifested by:
process initiated
nurse to identify the
a. Temperature
development of the d. Temperature

within
normal
patients
within normal
Vascular changes
range (36.4 to
temperature.
range (36.4 to
(Vasodilation, capillary
permeability, blood flow)
37.2 C, axillary
37.2 C, axillary
temperature for 3. Monitor other vital 3.Hyperventilation may
temperature for

infants)
signs such as
infants)
initially be present.
Cellular changes
respiratory and
( leukocytes, release of
Dysrhythmia may be
chemical mediators)- as a b. Relief of signs of
pulse rates.
due to direct effects e. No signs of
compensatory mechanism
discomfort such
discomfort such
of hyperthermia on

as grimacing and
as grimacing
blood and cardiac
Local effects
crying
and crying
tissue.
(erythema, warmth,
swelling, pain,
c. Other vital signs 4. Monitor ventilatory 4.Ventilatory effort may f.Other vital signs
impaired functioning)
within normal
effort.
within normal
be impaired due to
range
range
hypermetabolic state

and possible
Systemic effects
for newborns-neonate:
For newborns-neonate:
seizures.
(FEVER, malaise)
RR: 20-40
RR: 20-40
breaths/min
PR (apical): 75-155
beats/min

5. Monitor/record all
5.Fluids and electrolytes
sources of fluid loss
may be loss due to
such as urine,
dehydration.
vomiting, diarrhea,

breaths/min
PR (apical): 75-155
beats/min

wounds, insensible
losses.
6. Administer
antipyretics as
ordered.

6. To reduce fever. Do
not give aspirin and
related drugs as it
may cause Reyes
syndrome.

7. Promote surface
7. Promotes heat loss
cooling by means of
by radiation and
undressing or
conduction.
wearing light-weight
clothing.
8. Perform tepid
sponge bath. Avoid
too much exposure
of infant as it may
cause chills.

8. Promotes heat loss

by evaporation and
conduction.

9. Place a cool cloth

(not ice) on the
infants forehead.

9. Gives a cooling
sensation;
comforting to the
infant.

10. Promote fluid

intake; Administer
replacement fluids
and electrolytes.

10. To replace lost fluids

and to support
circulating volume
and tissue
perfusion.

11. Maintain bed rest.

11. Reduces metabolic

demand/ oxygen
consumption.

12. Administer
12. To treat underlying
medications such as
cause.(ex: infection)
antibiotic as
ordered.

13. Teach guardian not

to give the patient
13. Drugs may cause
OTC drugs or
serious adverse
aspirin. Follow
effects on the infant;
medications
may impair renal
prescribed by the
and hepatic function
physician.
if given on wrong
doses.
14. Discuss to guardian
the importance of
14. To prevent
adequate fluid
dehydration.
intake of the patient.
15. Teach guardian not
to cover the patient 15. Covering the infant
with thick clothing or
tightly will increase
blanket; attend
the temperature
immediately to
further and does not
patients needs.
prevent shaking or
trembling
associated with high
fever. Attending to
the patients needs
decreases
discomfort.

PAMANTASAN NG LUNGSOD NG MAYNILA

(University of the City of Manila)
Gen. Luna cor. Muralla Sts. Intramuros, Manila

College of Nursing

NURSING CARE PLAN ON:

SEPSIS/SEPTICEMIA
(ACTUAL)
RAZEL G. CUSTODIO
BSN III-3
TMC-PEDIA WARD
PROF. MANUELA TIRAZONA

Clinical Instructor