Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

SUBJECTIVE: Risk for Sepsis is a clinical After 8 hours of INDEPENDENT: · Body substance After 8 hours of
infection related term used to Nursing · Provide isolation isolation (BSI) Nursing
“Walng gana to compromised describe interventions, and monitor should be used interventions,
dumede ang immune system. symptomatic the patient will visitors for all infectious the patient was
anak ko, parang bacteremia, with achieve timely as indicated. patients. Reverse able to achieve
mainit sya at or healing and free isolation/restricti timely healing
matamlay” (it’s without organ from further on of visitors and free from
difficult to feed my dysfunction. infection. may be needed further infection.
baby, she feels Sustained to protect the
warm to touch and bacteremia, in immunosuppress
not very active) as contrast to ed patient.
verbalized by the transient
mother. bacteremia, may · Reduces risk of
result in a · Wash hands cross
OBJECTIVE: sustained febrile before contamination
response that may or after each care because gloves
· Increased be associated with activity, even may have
body organ dysfunction. gloves noticeable
temperature. Septicemia refers are used. defects, get torn
· Flushed skin. to or damaged
· Increased the active during use.
respiratory multiplication of
rate. bacteria in the · Prevents spread
· V/S taken as bloodstream that of infection via
follows: results in an airborne droplets.
T: 37.7 overwhelming · Limit use of
P: 130 infection. invasive devices
R: 45 or · May provide clue
procedure as to portal entry,
possible. type of primary
infecting
· Inspect wounds organisms, as well
or as early
site of invasive identification
devices, paying secondary
particular infection.
attention
to parenteral lines. · Prevents
introduction of
bacteria,
reducing risk of
· Maintain sterile nosocomial
technique when infection.
changing
dressings, · Used to reduce
suctioning or fever.
providing site
care.
· Chills often
Precede
· Provide tepid temperature
sponge bath and spikes in presence
avoid use of of
alcohol. generalized
infection.
· Observe for chills
and profuse · May reflect
diaphoresis. inappropriate
antibiotic therapy
or overgrowth of
¨ Monitor for signs secondary
of infections.
deterioration of
condition or failure
to improve in
therapy. · Identification of
portal entry and
COLLABORATIVE organism causing
: the septicemia is
crucial in effective
· Obtain treatment.
specimens of
urine, blood, · To prevent
sputum, wound as further spread of
indicated for gram infection.
stain, and
sensitivity.

· Administer
antibiotics
As prescribed.
 Drug Name Drug Dosage Action Adverse Reaction Contraindication Nursing
Classification Intervention

Ampicillin Antibiotic, Usual Bactericidal Adverse effects • Contraindicated • Culture infected

Penicillin dosage action reported with allergies to area before
against sensitive with ampicillin are penicillins, treatment;
range: organisms; similar to those cephalosporins, or reculture area if
inhibits reported with other other allergens response is not as
Infants and synthesis of aminopenicillins; • Use cautiously expected.
Children: bacterial cell however, diarrhea with
wall, causing cell and renal disorder. • Check IV site
Oral: 50-100 death. rash have been carefully for signs
reported of thrombosis or
mg/kg/day in
more frequently with drug reaction.
doses divided ampicillin than with
every 6 hours other currently
• Do not give IM
(maximum: 2- available
injections in the
4 g/day) aminopenicillins.
same site; atrophy
can occur. Monitor
I.M., I.V.: 100- injection site.
400
mg/kg/day in • Administer oral
divided doses drug on an
empty stomach, 1
every 6 hours
hr before o 2 hrs
(maximum: after meals with a
12 g/day) full glass of water;
do not give with
Adults: Oral, fruit juice or soft
I.M., I.V.: 250- drinks.
500 mg every
6 hours