F.

NCP Proper

NURSING CARE PLAN

DATA EXPLANATION OF THE OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

PROBLEM

Subjective: Incomplete vaccination STO: After 8 hours of Dx: STO: After 8 hours of
> Mother of BCG (Bacillus nursing interventions, > Monitor vital signs > It is important to nursing interventions,
verbalized, “Wala Calmette-Guérin) the mother of the immediately take the mother of the
pa daw siyang increases the risk of patient will note of the patient will
BCG.” infections in newborns enumerate 3 temperature for high enumerate 3
due to the loss of potential risks of fever, respiratory rate potential risks of
Objective: protection against incomplete for dyspnea or DOB, incomplete
> Initial vital signs tuberculosis (TB) and immunization, such and SPO2 for immunization, such
are as follows: other mycobacterial as: decreased as:
T = 37.3 C infections. BCG a. Increased risk oxygenation in the a. Increased risk
CR = 156 bpm vaccination is designed of severe illness blood. of severe illness
RR = 56 cpm to provide immunity b. Delayed or b. Delayed or
SpO2 = 98% against TB, which is a disrupted > Assess the patient’s > Drastic changes in disrupted
> Good suck and highly contagious and development weight, consistency weight, feeding, and development
has proper potentially of baby of feeding, and nutritional status may of baby
latching to the life-threatening disease. c. Missed social nutritional status. indicate malnutrition, c. Missed social
mother When newborns do not and which contributes to and
> Has rooting receive the complete educational decreased immune educational
reflex BCG vaccination, their opportunities capabality and opportunities
> Has positive immune system remains for baby increased risk for for baby
babinski reflex vulnerable to TB and infection.
> Exhibits loud cry other mycobacterial LTO: After 72 hours of GOAL MET IF:
in response to infections, increasing the nursing interventions, > Monitor for signs of > Early detection of After 8 hours of
stimulation likelihood of infection the patient will infection, such as infection allows for nursing interventions,
> Anthropometric and its associated remain free of fever, increased WBC prompt treatment. the mother of the
measures as complications. infection, as count, and DOB patient was able to
follows: evidenced by: enumerate 3
- Birth BCG vaccination a. Normal vital Tx Dependent: potential risks of
weight: stimulates the immune signs, and > Newborn screening > Completing incomplete
3.320 kg system to recognize and b. The absence done newborn screening immunization, such
- Birth length: respond to of signs and helps identify and as:
51 cm Mycobacterium symptoms of treat certain genetic a. Increased risk
- Head tuberculosis, the infection, such and metabolic of severe illness
circumfere bacterium that causes as fever, conditions early, b. Delayed or
nce: 33 cm TB. It helps in the reduced preventing potential disrupted
- Abd. development of specific energy, and long-term health development
circumfere immune responses that difficulty complications. of baby
nce: 30 cm can effectively control breathing. c. Missed social
> Hepatitis B and eliminate the TB Tx Independent: and
vaccine 0.5 ml IM bacteria. Incomplete > Performed hand > Hand washing educational
was administered vaccination leaves hygiene by washing reduces the likelihood opportunities
on the right newborns with of hands before and of transmitting for baby
anterolateral inadequate immune after touching the pathogens to the
thigh protection, making them baby for assessment newborn that can GOAL PARTIALLY MET
> Vitamin K 10 more susceptible to TB cause infection. IF: After 8 hours of
mg/ml IM on the infection. nursing interventions,
left anterolateral Moreover, BCG > Facilitated > Continuous, the mother of the
thigh vaccination also offers breastfeeding with effective, and patient was able to
> Crede’s cross-protection against the mother every 2 exclusive enumerate 2 or 1
Prophylaxis with non-tuberculous hours or per demand breastfeeding helps potential risks of
Terramycin mycobacteria (NTM) boost the immune incomplete
ointment strip on infections. NTM are system of the baby immunization, such
both eyes given mycobacterial species through passive as:
at the 1st hour of other than M. immunity of the a. Increased risk
life. tuberculosis that can mother. of severe illness
cause various diseases in b. Delayed or
Nursing Diagnosis: humans. Incomplete Edx: disrupted
Risk for infection BCG vaccination
related to reduces the immune
incomplete response against NTM,
immunization increasing the risk of NTM
after birth infections in newborns.
Therefore, the rationale
behind the increased risk
of infections in newborns
with incomplete BCG
vaccination lies in the loss
of protection against TB
and NTM infections.
Complete BCG
vaccination is crucial to
provide newborns with
the necessary immune
defenses against these
pathogens, reducing the
risk of infections and their
associated
complications.
> Encouraged the > Proper and development
mother to be more frequent hand of baby
frequent on proper washing prevents the c. Missed social
hand hygiene in spread of infectious and
handling foods and diseases, especially educational
materials nosocomial ones opportunities
while still in the for baby
hospital.
> Emphasized to the GOAL NOT MET IF:
mother the > The baby needs to After 8 hours of
importance of be woken up even if nursing interventions,
consistent she was sleeping to the mother of the
breastfeeding every 2 support adequate patient was not able
hours or per demand nutrition that is to enumerate any
to boost immunity of needed by the body. potential risks of
baby incomplete
immunization, such
> Instructed to limit as:
visitors and not > Reducing visitation a. Increased risk
participate in public and immediate of severe illness
outings for the first exposure to the b. Delayed or
few weeks public places lowers disrupted
the chance of development
spreading pathogens of baby
to the patient. c. Missed social
Collaborative: and
> Discuss with the educational
physician about the > With the physician opportunities
BCG vaccine that discussing matters for baby
has not been given to about immunization
the baby to the mother, this LTO: After 72 hours of
increases the chance nursing interventions,
of compliance in the the patient will
family to adhere to remain free of
routine vaccination. infection, as
evidenced by:
a. Normal vital
signs, and
b. The absence
of signs and
symptoms of
infection, such
as fever,
reduced
energy, and
difficulty
breathing.

GOAL MET IF:

After 72 hours of
nursing interventions,
the patient remained
free of infection, as
evidenced by:
a. Normal vital
signs, and
b. The absence
of signs and
symptoms of
infection, such
as fever,
reduced
energy, and
difficulty
 breathing.

GOAL PARTIALLY MET

IF:
After 72 hours of
nursing interventions,
the patient able to
free of infection, as
evidenced by only
one these:
a. Normal vital
signs, and
b. The absence
of signs and
symptoms of
infection, such
as fever,
reduced
energy, and
difficulty
breathing.

GOAL NOT MET IF:

After 72 hours of
nursing interventions,
the patient did not
remain free of
infection/s.