NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

INDEPENDENT:
SUBJECTIVE: Risk for Sepsis is a clinical After 8 hours of • Provide isolation • Body substance After 8 hours of
infection related term used to nursing and monitor visitors isolation (BSI) nursing
“Walng gana to compromised describe interventions, as indicated. should be used interventions,
dumede ang immune symptomatic the patient will for all infectious the patient was
anak ko, parang system. bacteremia, with or achieve timely patients. Reverse able to achieve
mainit sya at without organ healing and free isolation/restricti timely healing
matamlay” (it’s dysfunction. from further on of visitors and free from
difficult to feed my Sustained infection. may be needed further
baby, she feels to protect the infection.
warm to touch and bacteremia, in
contrast to immunosuppress
not very active) as
transient ed patient.
verbalized by the
mother. bacteremia, may
result in a • Wash hands before • Reduces risk of
sustained febrile or after each care cross
OBJECTIVE:
response that may activity, even gloves contamination
be associated with are used. because gloves
• Increased
organ dysfunction. may have
body
Septicemia refers to noticeable
temperature.
the active defects, get torn
• Flushed skin.
multiplication of or damaged
• Increased
bacteria in the during use.
respiratory
rate. bloodstream that
results in an • Limit use of invasive • Prevents spread
• V/S taken as
overwhelming devices or of infection via
follows:
infection. procedure as airborne
possible. droplets.
T: 37.7
P: 130
• Inspect wounds or • May provide clue
R: 45
site of invasive to portal entry,
devices, paying type of primary
particular attention infecting
to parenteral lines. organisms, as
well as early
identification
secondary
infection.
• Maintain sterile • Prevents
technique when introduction of
changing dressings, bacteria,
suctioning or reducing risk of
providing site care. nosocomial
infection.

• Provide tepid • Used to reduce

sponge bath and fever.
avoid use of alcohol.

• Observe for chills • Chills often

and profuse precede
diaphoresis. temperature
spikes in
presence of
generalized
infection.

♦ Monitor for signs of • May reflect

deterioration of inappropriate
condition or failure antibiotic therapy
to improve in or overgrowth of
therapy. secondary
infections.

COLLABORATIVE:
• Obtain specimens of • Identification of
urine, blood, portal entry and
sputum, wound as organism causing
indicated for gram the septicemia is
stain, and crucial in
sensitivity. effective
treatment.

• Administer anti- • To prevent

biotics as further spread of
prescribed. infection.