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NCP

1) The nursing care plan is for a newborn male patient in the NICU diagnosed with HMD versus neonatal pneumonia and rule out sepsis. 2) The goals are for the patient to be free from infection. Objectives include wound healing and improvement, being free of signs of infection, and teaching handwashing. 3) Planned nursing interventions include wound care, gentle handling, keeping linens dry, good perianal hygiene, and teaching handwashing to prevent infection.

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Faye Spring Travilla
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2K views

NCP

1) The nursing care plan is for a newborn male patient in the NICU diagnosed with HMD versus neonatal pneumonia and rule out sepsis. 2) The goals are for the patient to be free from infection. Objectives include wound healing and improvement, being free of signs of infection, and teaching handwashing. 3) Planned nursing interventions include wound care, gentle handling, keeping linens dry, good perianal hygiene, and teaching handwashing to prevent infection.

Uploaded by

Faye Spring Travilla
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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NURSING CARE PLAN

Name of Student: Faye S. Travilla Date of Assignment: September 20, 2010

Name of Patient: Baby of Francisca Danao Sex: Male Ward: Nicu


Diagnosis: HMD versus neonatal pneumonia, r/o sepsis

CUES NURSING BACKGROUND KNOWLEDGE GOALS AND NURSING EVALUATION


DIAGNOSI OBJECTIVES INTERVENTION
S AND
RATIONALE
Subjective: PC: Sepsis Newborns, especially those in the Goal: The student
• N/A NICU, are very prone to infection The client will be free nurse will:
(Rubarth, 2008). Add to this is from infection.
the fact that underage newborns
Objective: have an underdeveloped Objectives:
• VS: immune system. This is why After the intervention,
>T= 36.2 C, special care must be made to the client will: PE:
axillary ensure that pathogens will be
>HR = 120 bpm prevented from having contact 1)be free of/display 1)>Do wound >Decreased wound
>PR = 120 bpm with the patient. improvement in care as indicated diameter
• Looks wound/lesion healing for client’s case
younger Rationale: >(-) swelling, (-)
than age Keeping the warmness, (-) pus
• Premature wound clean and
: 35 wks dry facilitates >(-) white patches in
by PA body’s natural mouth
process of
• Small for
healing and >(-) cracks in lips
gestationa
provides barrier
l age: 0.85
to infection. (SO) Performed
kg
handwashing
• on correctly (30
warmer >provide/instruc seconds, with soap
with t in oral care: and vigorous
temperatu daily and after rubbing)
re probe food intake
to Rationale: this
abdomen alleviates
• poor discomfort
sucking prevents acid
reflex formation
• umbilical associated with
cord not retained food
totally particles and
healed promotes feeling
of well-being
Labs:
CBC (9/18/10) >handle patient
WBC – 17 (↑) gently. Keep
Neutrophils – linens
0.45 (↓) dry/wrinkle free.
RDW – 25.4 (↑) Rationale: This
MCHC – 368 (↑) prevents sheet
MCH – 85 (↑) burn/skin
HCT – 0.332 (↓) excoriation
RBC – 3.91 (↓) thereby
preventing
future invasion
site for
pathogens.

>promote good
perianal hygiene.
Avoid rectal
temperatures or
use of
suppositories.
Rationale:t his
promotes
cleanliness,
reducing risk of
perianal abscess;
also enhances
circulation and
healing.
Note: perianal
abscess can
contribute to
septicemia and
death in
immunocompres
sed patients.

2)>Teach/instruc
t handwashing to
client and SOs
Rationale: proper
handwashing is
proven to
prevent cross-
contamination/re
duce risk for
infection

Doenges, M., Moorhouse, M. F. & Murr, A. (2006). Nurse’s pocket guide: Diagnoses, prioritized interventions and rationales. Philadelphia: F.A.
Davis

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