Assessment

Nursing
Diagnosis

Subjective:

Objective:
Patient is
diagnose
d with
neonatal
sepsis
upon
admission
Vital Sign
RR;43cycl
es/min
HR:152
bpm
TEMP:
36.8
WT: 2.94
kg
Increased
WBC

Risk for infection r/t

spread of
pathogens
secondary to
identified sepsis
and immature
immune system
Scientific reason:
The newborns
immune system is
not fully activated
until sometime
after birth.
Limitation in the
newborns
inflammatory
response result in
failure to
recognize,
localize, and
destroy invasive
bacteria thus,
increasing risk for
infection

Outcome
Short term goal:
After 8 hrs of nursing
intervention
the infant will free from
further infection
Long term goal:
After several days of
nursing intervention
infection will be prevented.

Nursing
Interventions
INDEPENDENT
1. assess TPR
&BP,
auscultate
breath
sounds
Assessments
provide
information
about the spread
of infection,
increased RR
and HR,
decreased BP
are signs of
sepsis. Spread
of infection may
cause resp.
distress
.
2. Ensure that
all people
coming in
contact with
infant wash
their hands
well before &

Evaluation
Standard
Criteria
The infant
will exhibit
no signs of
infection.

After 8 hrs
of nursing
intervention
the infant
are
Free from
further
infection.

level 29.3

after touching
the baby
Hand washing
prevents the
spread of
pathogens
coming from the
infant to the
caregiver and
vice versa
3. Ensure that
all equipment
used for
infant is
sterile,
scrupulously
clean
&disposable.
Do not share
equipment
with other
infants
this would
prevent the
spread of
pathogens to the
infant from
equipment
4. Place infant

in isolette/
isolation
room per
hospital
policy
placing the infant
in an isolette
allows close
observation of
the ill neonate
&protects other
infants from
infection
5. maintain
neutral
thermal
environment
A neutral thermal
environment
decreases the
metabolic needs
of the infant. The
ill neonate has
difficulty
maintaining a
stable temp
6. Provide
respiratory
support
(oxyhood)
resp. support

may be needed
during the acute
phase of the
infection to
prevent
additional
physiological
stress
7. Monitor lab
results as
obtained.
Notify care
giver/physicia
n of abnormal
findings
lab results
provide
information
about the
pathogen and
infants response
to illness and
treatment
8. monitor infant
for
hypoglycemia
, jaundice,
development
of thrush, or
signs of
bleeding

 Assessments
coagulation
provide
information
about the
development of
complications of
infection:
hypoglycemia,
hyperbilirubenia,
opportunistic
infections, and
coagulation
deficits.
9. feed infant as
ordered
(OGT)
Nutritional needs
may increase
during infection
while the infant
may feed poorly.
OG feedings
ensure that
nutrient needs
are met if the
infant is too ill to
suck effectively
10. administer IV
fluids as
ordered(D10I

MB
IV fluids help
maintain fluid
balance
11. Administer
antibiotics as
ordered.
antibiotics act to
inhibit the growth
of bacteria and
destruction of
bacteria.