Nursing Care Plan Nursing Diagnosis: Risk for infection related to inadequate acquired immunity; and inadequate primary

defences secondary to impaired skin integrity. Nursing Inference: A newborn baby has underdeveloped immune system. Immune system is involved in protecting the baby from pathogens which may possibly harm. As time passes by immunity is developed through exposure to minimal level of antigens from the environment and even from weakened microorganisms like vaccines. The acquired immunity developed will combat the non-self antigens brought about by pathogens, hence preventing infection to occur. In addition, the impaired skin integrity brought about by IV therapy could predispose the immunodeficient neonate to sepsis, hence risk for infection. Nursing Goal: After 2-3 days of rendering effective nursing interventions the mother will be able to identify, demonstrate ways to prevent infection. Nursing Responsibilities with Rationale: 1. Educate mother about the importance of prevention of infection to facilitate cooperation. 2. Observe for localized signs of infection at insertion sites of invasive lines like redness, edema and warmth in the site. These observations will serve as basis for medical intervention. 3. Note for signs and symptoms like fever, chills, diaphoresis, altered level of consciousness and positive blood cultures as these data are manifestations for sepsis and prompts for medical intervention. 4. Perform aseptic techniques in administering intravenous medications. An impaired tissue especially the blood vessel is a good portal for infection. 5. Administer prophylactic antibiotic medications as ordered to prevent specific infections which can be fought by the antibiotics. 6. Administer immunizations (like BCG and Hepa B) as ordered to prevent infection associated to pulmonary tuberculosis and hepatitis B. 7. Educate mother the importance of immunizations to promote adherence. 8. Instruct to the mother the importance of proper hand washing. Hand washing is a firstline defense against healthcare-associated infections (HAI). 9. Monitor clients visitors/caregivers for respiratory illnesses. Offer masks and tissues to client/visitors who are coughing/sneezing to limit exposures, thus reduce crosscontamination. 10. Encourage mother to promote proper personal hygiene and bathe baby daily to reduce microorganisms in the body which may predispose infection. 11. Change the IV catheter every 24-48 hours to reduce infection. 12. Document things performed to the client, like administration of antibiotics and vaccines. These things will serve as basis for continuity of care and for legal basis.

Nursing Evaluation: After 3 days of rendering effective nursing interventions the mother was able to identify, demonstrate ways to prevent infection.