ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective Cues: Risk for infection r/t Within 2 hours of  Reduce the risk of 
- presence of blood clot presence of dried up nursing intervention,  Note risk factors for potential spread of  Absence of blood on
at the baby’s exposed blood at the clamped the infant will occurrence of infection. infection the cord clamp
umbilical cord umbilical cord remain free of  Assess and document  To know the overall  Umbilical stump
- redness around the infection as skin conditions around condition around the appeared dry and is
umbilical cord and at the evidenced by: the base of the umbilical exposed umbilical healing well
baby’s abdomen 1. Cord clamp is cord cord.  Absence of foul odor
- free from presence  Perform Cord Care.  To properly clean the and free from
of blood Observe newborn for umbilical cord ad secretions
2. Umbilical cord is signs and symptoms of prevent further  Vital signs within
healing and free of infection. Assess cord for infections normal range
infection erythema, bleeding, foul  So that the baby’s  T = 37 °C
3. Area around the odor and purulent umbilical cord will be  CR/PR = 125 bpm
base of the cord is discharge taken care of even at  RR = 30-60 breaths/pm
free from any  Instruct mother to always their home.
discharge clean the baby’s  So that the mother will
4. Vital signs umbilical cord, by using have knowledge about
remain within proper cord care. the risks of an infected
normal range  Teach the mother the umbilical cord
risks if she won’t follow
the proper cleaning of
her baby’s umbilical cord

Name of Student: Yvone Zoe Ordista

Placement: BSN 2B3