A Nursing Care Plan On

RISK FOR INFECTION

In Partial Fulfillment of the

Requirements in NCM 209-RLE

DELIVERY ROOM/NICU NURSING ROTATION

Submitted to:

MRS. ANGELIQUE ANNE A. LOQUEZ, RN

Clinical Instructor

Submitted by:

NOAH EMMANUEL G. SOMBILON, St. N

BSN 2D-GROUP 1

April 21, 2020

Name of Patient: A.B. Age/Gender: 30/F Ward: Labor Room Room no: 4______
Chief Complaint: Passage of watery vaginal discharges Physician: Dr. A. Loquez
Diagnosis: G4P3 30 weeks AoG Preterm Premature Rupture of Membranes .
Date/ Cues Need Nursing Diagnosis Objectives of Care Nursing Interventions Impleme Evaluation
Time / Patient Outcome ntations

A Subjective: N Risk for infection At the end of 1 A. @ April 20, 2020

P “Actually, U related to potential day (7-3) shift duty  Monitor vital signs 1 3pm
R kaganihang T bacterial spread (April 20, 2020), R: To check underlying
I kadlawon R associated with my patient will be conditions such as “Goal Completely
L mura kog I preterm premature able to: pregnancy complications, to Met”
nakaihi, T rupture of provide further interventions.
2 akong I membranes a. maintain a  Administer acetaminophen 8 At the end of 1 day
0 gihikap- O temperature as prescribed by the health (7-3) shift duty (April
, hikap ug N Risk for infection is lesser than care provider. 20, 2020), my
gisimot dili A defined as 37.9 degrees R: To lessen the fever of patient is able to:
2 man bahog L susceptible to Celsius, patient which may be caused
0 ihi ug - invasion and b. maintain non- by other factors; promotes a. have a
2 tubigon jud M multiplication of malodorous comfort from the illness temperature of
0 siya” as E pathogenic secretions state. 37.0 degrees
verbalized T organisms which which can be Celsius,
@ by patient A may compromise a sign of B. b. maintain non-
7 B health. When the infection, and  Observe vaginal secretions 2 malodorous
A “Syempre O bag of water is c. demonstrate for color, amount and odor secretions
M nagkara- L ruptured, the fetus is appropriate q8h. wherein scanty
kara ko wa I susceptible to hygienic R: Vaginal discharge urine is not
nako kailis C infection as the measures in characteristics are signs of observed, and
ug panty, so amniotic sac plays a preventing infection. Prompt notification c. demonstrate
basa jud ni P vital role in bacterial of these signs to the health appropriate
pagadmit A protecting the fetus spread. care provider may decrease hygienic
nako” as T from bacterial the risk of further measures in
verbalized T infections. The compromise to the fetus or preventing
by patient E mother perhaps be mother. bacterial
R at risk of ascending  Palpate uterus for uterine 3 spread such as
Objective: N infection that leads tenderness. handwashing,
Temp: 37.5 to chorioamnionitis R: Uterine tenderness can perineal
degrees or maternal sepsis also be a sign of infection. cleaning from
Celsius wherein the vaginal Providing immediate front to back,
PR: 93 bpm orifice when in intervention will prevent showering daily
RR: 21 cpm contact with the further complications. and changing
CR: 95 bpm surroundings with  Encourage fluid intake. 4 of peripad
BP: 120/80 bacteria, it can be a R: fluid intake helps replace when needed.
mmHg portal of entry. lost fluids from the
When the vaginal complication.
G4P3A0 orifice has lesser  Collect serial maternal 9 Noah Emmanuel G.
acidity due to specimens of blood for Sombilon, St. N
T2P1A0L3 amniotic fluid, Complete Blood Count
bacterial spread (CBC) and urine for
AOG: 30 may occur. urinalysis as prescribed by
weeks health care provider.
R: White blood cell
References:
Immunoass differential rises with
ay PAMG-1 infection. Bacteria are
Result: 2 Herdman T., & present in the urine if a
lines (+) Kamitsuru, S. urinary tract infection
Covering the (2018). Nursing develops.
vagina using diagnoses  Apply an Electronic Fetal 7
bare hands definitions and Monitor (EFM) and perform
classification 2018- nonstress test.
CBR without 2020 (11th ed.). New R: Fetal heart rate with
BRP York: Thieme variable decelerations, late
decelerations or decreased
Medical variability are associated
order of with fetal compromise and
Erythromyci indicate a need for further
n 250mg PO testing or action. Fetal
q6 tachycardia is a sign of
infection.
Paracetamol  Arrange for other tests of 10
500mg PO fetal well-being such as
q6 Biophysical Profile (BPP)
and phosphatidyl glycerol
(PG).
R: BPP assesses deviations
in growth and development
and assesses for subclinical
infection and PG identify
lung maturity/readiness for
neonatal breathing.
 Administer antibiotics as 11
prescribed by the health care
provider.
R: Prophylactic antibiotics
prevent or reduce the effects
of maternal-fetal infections
and may reduce morbidity
and prolong the pregnancy.

C.
 Teach patient on the 5
importance of good hygiene
R: To add knowledge on the
significance of good hygiene.
 Instruct and assist patient 6
with proper hygiene
techniques such as frequent
hand hygiene, daily
showering, wiping the
perineum from front to back,
and changing the peripad
q2h (if peripad is worn)
R: These practices prevent
the spread of
microorganisms from the
environment to the genital
 area. A moist, warm peripad
foster bacterial growth.

References:
Ackley, B., Ladwig, G., & Makic,
M. (2016). Nursing diagnosis
handbook: an evidence-based
guide to planning care. St.
Louis, Missouri: Elsevier

Swearingen, P. (2016). All-in-

one nursing care planning
resource: Maternity nursing
care plans. St. Louis Missouri:
ELSEVIER