Assessment

Objective: -Patient is diagnosed with neonatal sepsis upon admission -RR;58 cycles/min -HR:148bpm -Labs increased WBC levels

Diagnosis
-Risk for infection r/t spread of pathogens secondary to identified sepsis and immature immune system

Planning
After 8 hours of nursing interventions the infant will not experience spread of infection as manifested by -Infants HR remains <160bpm -Infants RR is <60cycles/min

Nursing Intervention
INDEPENDENT: (1) ensure that all people coming in contact with infant wash their handswell before & after touching the baby

Rationale

Evaluation
After 8 hours of nursing interventions,the goal is fullymet. The infant did not experienced spread of infection as manifested by -Infants HR remained <160bpm

(1) handwashing prevents the spread of pathogens coming from the infant tothe caregiver and vice versa

(2) ensure that all equipment used for infant are sterile, scrupulously clean & disposable. Do not share equipment with other infants (3) assess TPR and auscultate breath sounds

(2) this would prevent the spread of pathogens to the infant from equipment

-RR was <60cycles/min

(3) assessments provideinformation about the spread of infection,increased RR and HR, decreased BP are signs of sepsis. Spread of infection may cause resp.distress (4) resp. support may be needed during the acute

(4) provide respiratory support (Oxyhood)

phase of the infection to prevent additional physiological stress (5) monitor lab results as obtained. Notify care giver of abnormal findings (5) lab results provide information about the pathogen and infants responseto illness and treatment

DEPENDENT: (6) administer IVfluids as ordered (7) administer antibiotics as ordered (6) IV fluids help maintain fluid balance (7) antibiotics act to inihibit growth of bacteria and destruction of bacteria.

Assessment
Objective: -Preterm birth (34 wks and2days) -With Oxygenhood regulated at 10 liters per minute -RR:58 cycles/min -Episodes of apnea (6- 10secs) -O2 saturation of 91%

Diagnosis
-Ineffective breathing pattern related to immature neurologic and delayed pulmonary development

Planning

Nursing Intervention

Rationale

Evaluation
-After 30 minutes of nursing interventions, goal is partially met, the infant experienced an effective breathing pattern as manifested by -Infants RR was between 40 and 60 -Infant experienced less episodes of apnea

-After 30 minutes of INDEPENDENT: nursing interventions, the (1) assessed RR and infant will pattern experience an effective breathing pattern as manifested by -Infants RR is between 40 and 60 -Infant will experience no apnea

(1)assessment provides information about neonates ability to initiate and sustain an effective breathing pattern (2)assistancehelps the newborn by clearing the airway and promoting oxygenation (3) lying on the side position facilitate breathing

(2) provided respiratory assistance as needed (oxygenhood) (3) positioned infant on side with a rolled blanket behind his back (4) provided tactile stimulation during periods of apnea

(4)stimulation of the sympathetic nervous system increases respiration