Nursing Care Plan for NEONATAL SEPSIS

ASSESSMENT NURSING DIAGNOSIS PLAN INTERVENTION

Related to Evidenced by
*Monitor neonate’s Hyperthermia Possibly evidenced by *Patient will maintain normal *Monitor neonate’s condition
condition. related to  Irritability core temperature as *Monitor vital signs
*Monitor vital signs inflammatory  Weakness evidenced by vital signs *Ensure that all equipment used for infant is
process/  Temperature above within normal limits and sterile, scrupulously clean. Do not share
normal level (36 oC) normal WBC level equipment with other infants
hypermetabolic
 Skin warm to touch *Patient will still maintain *Administer antipyretics as ordered
state as evidenced
 Presence of normal core temperature as
by an increase in
tachycardia (above 160 evidenced by normal vital
body temperature, bpm) signs and normal laboratory
warm skin and  Presence of tachypnea results.
tachycardia (above 60 bpm)
 WBC elevated

*Monitor and record Fluid Volume Possibly evidenced by
vital signs. Deficit related to  Decreased urine outpu
*Monitor intake and failure of t functional level as evidenced
output chart regulatory  Increased urine
concentration
mechanism
 Increased pulse
rate (above 160 bpm)
 Decreased body
temperature (above 36
oC)
 Decreased skin turgor
 Dry skin/ mucous
membranes
 Elevated hct
*Patient will be able to
maintain fluid volume at a
by individually adequate
urinary output with normal
specific gravity, stable vital
signs, moist mucous
membranes, good skin
turgor and prompt capillary
refill and resolution of
edema.
*Monitor and record vital signs
*Note for the causative factors that contribute
to fluid volume deficit
*Provide tepid sponge if patient has fever
*Provide oral care by moistening lips & skin
care by providing daily bath
*Administer IV fluid replacement as ordered
*Administer antipyretic drugs if patient has
fever as ordered

*Note quality and Ineffective Tissue Possibly evidenced by *Patient will demonstrate *Note quality and strength of peripheral
strength of peripheral Perfusion related  Skin or temperature increased perfusion as pulses
pulses to impaired changes evidenced by warm and dry *Assess respiratory rate, depth, and quality
Nursing Care Plan for NEONATAL SEPSIS
*Assess respiratory rate, transport of  Weak pulses skin, strong peripheral *Assess respiratory rate, depth, and quality
depth, and quality oxygen across  Edema pulses, normal vital signs, *Assess skin for changes in color, temperature
alveolar and on  Inadequate urine adequate urine output and and moisture
capillary output absence of edema *Elevate affected extremities with edema once
in a while
membrane
*Provide a quiet, restful atmosphere

*Assess mother’s Interrupted Possibly evidenced by *The mother will identify and *Give emotional support to mother and
perception and breastfeeding  The mother unable to demonstrate techniques to accept decision regarding cessation/
knowledge about related to provide breast milk to sustain lactation until continuation of breast feeding.
breastfeeding and neonate’s present newborn continuously breastfeeding is initiated *Demonstrate use of manual piston-type
extent of instruction that illness as *The mother shall still be breast pump.
has been given evidenced by able to identify and *Review techniques for storage/use of
separation of demonstrate techniques to expressed breast milk
mother to infant sustain lactation and identify *Provide privacy, calm surroundings when
techniques on how to mother breast feeds.
provide the newborn with *Recommend for infant sucking on a regular
breast milk. basis
*Encourage mother to obtain adequate rest,
maintain fluid and nutritional intake, and
schedule breast pumping every 3 hours while
awake
* Assess mother’s Risk for Impaired Possibly evidenced by *The mother will identify and *Interview parents, noting their perception of
perception and Parent/Infant  The mother unable to demonstrate techniques to situational and individual concerns
knowledge about Attachment provide breast milk to enhance behavioral *Educate parents regarding child growth and
breastfeeding and related to newborn continuously organization of the neonate development, addressing parental
extent of instruction that *After discharge the parents perceptions
neonates physical
has been given will be able to have a *Involve parents in activities with the newborn
illness and
mutually satisfying that they can accomplish successfully
hospitalization.
interactions with their *Recognize and provide positive feedback for
newborn. nurturing and protective parenting behaviors