ASSESSMENT

DIAGNOSIS

PLANNING

IMPLEMENTATION

EVALUATION

Objective:

Risk for infection related to immature immune response and extra uterine exposure

Be free of signs of infection such as temperature instability, respiratory distress and purulent discharge or secretions

Independent:  Promote meticulous hand washing. Hand washing is the most important practice for preventing crosscontamination.  Assess infant for signs of infection, such as temperature instability, respiratory distress, petechiae, nasal congestion, or drainage from eyes or umbilicus. Useful in the diagnosis of infection; temperature alone is not reliable for preterm infant with impaired inflammatory response.  Perform care of umbilical cord according to hospital protocol. Local application of alcohol various antimicrobials helps prevents colonization.  Breast milk for feeding, if available.

Goal met. After 8 s hours of duty, the infants did not show any signs of infection such as temperature instability, respiratory distress and purulent discharge or secretions.

Breast milk contains IgA, macrophages, lymphocytes, and neutrophils, which provide some protection from infection. Collaborative:  Obtain specimens as indicated (e.g., urine through aspiration, blood, CSF, visible skin lesions, nasopharynx, or sputum, if infant is intubated Cultures/sensitivity tests are necessary to diagnose pathogens and identify appropriate therapy. Educative: Teach caregiver the signs and symptoms of infection in the umbilical cord (redness, swollen umbilical stump, green and yellow discharge, bleeding). Encourages immediate response if infection occurs.