VI.

NURSING MANAGEMENT Nursing Care Plan Problem #1: Risk for Infection

Cues S: O: pt. may manifest: > Invasive procedures (amniocentesis or intrauterine blood transfusion >Insufficient knowledge to avoid exposure to pathogen > inadequate secondary defenses (e.g., decreased hemoglobin, leukopenia, suppressed inflammatory response); > rupture of amniotic membranes

Nursing Diagnosis Risk for infection r/t impaired primary defense.

Scientific Explanation The patient is at risk of acquiring infection due to the break in the continuity of the first line defense which is the skin. The patient shall have undergone amniocentesis or intrauterine blood transfusion thus there is an incision and suture made in the abdomen. If there is a breakage in the skin, the pathogens will easily invade the bodys system thus increasing risk for infection

Objectives

Nursing Interventions

Rationale

Evaluation

Monitor v/s and After 1 hour of assess patients nursing interventions, the condition patient will Observe and demonstrate report signs of techniques in infection such as reducing risk of redness, warmth, having infection discharge, and increased body temperature. Stress the importance of proper hand washing Strict compliance to hospital control, sterilization, and aseptic policies

For baseline data

Were the vital signs stable?

With the onset of infection the immune system is activated and signs of infection appear.

Are there any changes skin color discolorations and body temperature?

A first line defense against nosocomial infection or cross contamination To establish mechanism to prevent occurrence of infection

Did the client understand the handwashing technique properly?? Is SOP for hospital sterilization properly monitored? Are there any side effects to the antibiotic treatment? Did the patient follow the prescribed medications?

Tell patient to comply to antibiotic therapy as prophylaxis Monitor medication regimen

To prevent the occurrence of infection

To determine effectiveness of therapy

Problem #2: Risk for Fluid Volume Deficit related to Phototherapy

Cues

Nursing Diagnosis Risk for fluid volume deficit related to phototherapy

Scientific Explanation Phototherapy enhances the excretion of unconjugated bilirubin through the bowel.

Objectives

Nursing Interventions
> Initiate early feedings and offer feedings ever 2-3 hours

Rationale

Evaluation

OBJECTIVE: Clinical jaundice evident within 24 hour of birth

The infant will exhibit no signs of dehydration, clear amber urine output of 1-3 mL/kg/hr, and will display appropriate weight gain.

> To increase intestinal motility and promote the excretion of unconjugated bilirubin through the clearance of stools and to decrease the potential for dehydration

>Was early feeding initiated?

> Monitor urine specific gravity

> Urine specific gravity can be an indicator of dehydration. Dehydration and fluid volume deficit will show an elevation in the urine specific gravity > Additional fluids will help compensate for the increased water that is lost through the skin and in the stools

>What was the urines specific gravity?

>Administer fluid intake that is 25% above normal requirements

>Was fluid loss compensated?

>Were the

> Assess for signs of dehydrations such as poor skin turgor, depressed fontanels, sunken eyes, decreased urine output, weight loss, and changes in electrolytes > Monitor daily weight.

> Phototherapy treatment may cause liquid stools and increased insensible water loss, which increases risk of dehydration.

fontanels sunken? What was the skin turgor?

>Increased fluid excretion in the stools and a decrease in fluid intake may put the newborn at risk for weight loss. Daily weights can provide accurate determination fluid intake and insensible water loss that is caused by phototherapy

>Was there an increase on the daily weight?

> Assess quantity and characteristics of each stool.

> Loose stools indicate fluid loss which may lead to a fluid volume deficit. With an increase in stools per day, dehydration is possible.

>What was the characteristic of the stool?