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RLE 002

Cebu Normal University


College of Nursing
Cebu City
Mission-Vision: Care Using Knowledge and Compassion
Theory-based (Betty Neuman)

NURSING CARE PLAN


Assessment
Diagnosis

3 points
3 points

Goals
Theoretical Basis

2 points
2 points

Interventions
Evaluation

4 points
1 point

Bibliography
15 points

Name of Student:
Gervacio, Siergs Smith
Clients Initials: Baby Girl G.
Stressor Classification: (Please check)
Age: 6 days old Gender: Female Civil Status: Newborn Religion: Catholic
___*__ Physiological (body structure and functions)
Allergies: None
___x__ Psychological (mental processes and emotion)
Diet: Breast milk
___x__ Socio-cultural (relationships, social expectations)
Date of Admission: January 22, 2015
___x__ Spiritual (influence of spiritual beliefs)
Diagnosis/Impression: Meconium Aspiration Syndrome
___x__ Developmental (developmental processes over the lifespan)

NURSING DIAGNOSIS
Assessment
Subjective:
Ganahan naman mi
mu-uli sir kay kung
madugay mi diri basin
magkasakit nasad ni
akong anak.
As verbalized by the
patients mother.

Diagnosis

NURSING GOALS

Interventions

(Goal attainable within the


shift)

(with Rationale & Source)

Actual Evaluation

Within our care (8


PRIMARY INTERVENTIONS
hours), the newborn will: Promotive: Source : Nursess Pocket Guide p. 468
-471

Risk for infection r/t


immature immune
system

Objective:
6 days old.
6th day hospital
stay.

NURSING OUTCOME

Mutual Planning

Manifest no signs
of infection like
fever and chills
Vital Signs within
normal range
Normal breath
sounds
No reports of
increased
weakness or
fatigue
SO will verbalize
understanding of
individual

Monitor Vital Signs


R To determine any abnormal changes,
raise in temperature may indicate
infection.
Note risk factors for occurrence of
infection (Immunocompromised host,
sharing close quarters with other
patients, prolonged hospitalization)
R To assess causative/contributing
factors
Assess nutritional status, including
weight.
R - Patients with poor nutritional status
may be anergic, or unable to muster a
cellular immune response to pathogens
and are therefore more susceptible to
infection.

Vital signs
remained within
normal range
Temp = 36.4C
PR = 139 BPM
RR = 58 CPM
NB has normal
breath sounds
Absence of
heat, pain,
redness,
swelling, and
unusual
drainage in any
area
Newborn is free

Sharing close
quarters with
other patients.
History of
respiratory
distress
IV line of #4
D5IMB 500 cc @
11-12 cc/hr
infusing well on R
arm.
Baseline Vital
signs of:
T = 36.6 C
PR = 144 BPM
RR = 44 CPM

Theoretical basis:
The vast majority of newborns
enter the world healthy. But
sometimes, infants develop
conditions that require medical
tests and treatment.
Newborns are particularly
susceptible to certain diseases,
much more so than older
children and adults. Their new
immune systems aren't
adequately developed to fight
the bacteria, viruses, and
parasites that cause these
infections.
As a result, when newborns
get sick, they may need to
spend time in the hospital to
recover. Thats why I have
come up to a diagnosis of risk
for infection because of the
newborns immature system
and formulated a plan of care
proper for the newborn.

causative risk
Preventive: Source : Nursess Pocket Guide p.
468 -471
factors
Wash hands before and after providing
SO will identify
care to the patient
interventions to
R Hand washing is the single best way to
prevent or reduce
avoid spreading of pathogen

Anchor IV tubings.
risk of infection
R - in order to reduce trauma to the tissues
SO will
and the risk for introduction of pathogens
demonstrate
associated with the in-and-out movement
techniques,
of the tubing
lifestyle changes
Instruct and assist client to perform
good perineal care routinely and after
to promote safe

every bowel movement.


environment
R Proper perineal care reduces risk for
Demonstrates
infection. Teach front to back wiping
appropriate
maneuver.
hygienic measures SECONDARY INTERVENTIONS
such as hand
Curative Source : Nursess Pocket Guide p. 468 -471
washing.
Administer/monitor medication

regimen and note patients response.


R To determine effectiveness of therapy
or presence of side effects
Encourage mother to breastfeed every
2 hours and teach mother the
importance of breastfeeding.
R - Colostrum and breast milk contain high
amounts of immunoglobulin A, which
provides passive immunity and helps
reduce infection

TERTIARY INTERVENTIONS
Rehabilitative
Source : Nursess Pocket Guide p. 468 -471

Source:
http://kidshealth.org/parent/infection
s/
common/neonatal_infections.html

Instruct SOs in techniques to protect


the integrity of skin, care for lesions,
and prevention of spread of infections
R To avoid infection to the
immunocompromised.
Teach patient and caregiver the signs
and symptoms of infection, and when
to report these to the physician or
nurse.
R to allow early and prompt treatment
Teach mother childhood immunization
program (EPI).
R Immunization reduces risks of
acquiring diseases.

of signs and
symptoms of
infection such
as fever and
fatigue.
Mother had fully
understood the
importance of
breast feeding
in relation to
strengthening
the immunity
Demonstrates
appropriate
hygienic
measures and
verbalized its
importance
SOs
demonstrate
appropriate care
of infectionprone site (IV
site)

Bibliography:

Doenges, et al., (2010) Nurses Pocket Guide 12 th edition. F.A Davis Company, Philadelphia.
Kamis (2013). Risk for infection. [ONLINE] Available at: http://nursinginterventionsrationales.blogspot.com/2013/07/risk-for-infection.html. [Last Accessed 28
January 2015].
Audrey Klopp (2012). Infection, Risk for Universal Precautions; Standard Precautions; CDC Guidelines; OSHA. [ONLINE] Available at:
http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick33.html. [Last Accessed 28 January 2015].