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NURSING CARE PLAN

Name of Student: Faye S. Travilla Date of Assignment: September 20, 2010

Name of Patient: Baby of Francisca Danao Sex: Male Ward: Nicu


Diagnosis: HMD versus neonatal pneumonia, r/o sepsis

CUES NURSING BACKGROUND KNOWLEDGE GOALS AND NURSING EVALUATION


DIAGNOSI OBJECTIVES INTERVENTION
S AND
RATIONALE
Subjective: PC: Sepsis Newborns, especially those in the Goal: The student
• N/A NICU, are very prone to infection The client will be free nurse will:
(Rubarth, 2008). Add to this is from infection.
the fact that underage newborns
Objective: have an underdeveloped Objectives:
• VS: immune system. This is why After the intervention,
>T= 36.2 C, special care must be made to the client will: PE:
axillary ensure that pathogens will be
>HR = 120 bpm prevented from having contact 1)be free of/display 1)>Do wound >Decreased wound
>PR = 120 bpm with the patient. improvement in care as indicated diameter
• Looks wound/lesion healing for client’s case
younger Rationale: >(-) swelling, (-)
than age Keeping the warmness, (-) pus
• Premature wound clean and
: 35 wks dry facilitates >(-) white patches in
by PA body’s natural mouth
process of
• Small for
healing and >(-) cracks in lips
gestationa
provides barrier
l age: 0.85
to infection. (SO) Performed
kg
handwashing
• on correctly (30
warmer >provide/instruc seconds, with soap
with t in oral care: and vigorous
temperatu daily and after rubbing)
re probe food intake
to Rationale: this
abdomen alleviates
• poor discomfort
sucking prevents acid
reflex formation
• umbilical associated with
cord not retained food
totally particles and
healed promotes feeling
of well-being
Labs:
CBC (9/18/10) >handle patient
WBC – 17 (↑) gently. Keep
Neutrophils – linens
0.45 (↓) dry/wrinkle free.
RDW – 25.4 (↑) Rationale: This
MCHC – 368 (↑) prevents sheet
MCH – 85 (↑) burn/skin
HCT – 0.332 (↓) excoriation
RBC – 3.91 (↓) thereby
preventing
future invasion
site for
pathogens.

>promote good
perianal hygiene.
Avoid rectal
temperatures or
use of
suppositories.
Rationale:t his
promotes
cleanliness,
reducing risk of
perianal abscess;
also enhances
circulation and
healing.
Note: perianal
abscess can
contribute to
septicemia and
death in
immunocompres
sed patients.

2)>Teach/instruc
t handwashing to
client and SOs
Rationale: proper
handwashing is
proven to
prevent cross-
contamination/re
duce risk for
infection

Doenges, M., Moorhouse, M. F. & Murr, A. (2006). Nurse’s pocket guide: Diagnoses, prioritized interventions and rationales. Philadelphia: F.A.
Davis