Nursing Care Plan

Patient Name: Kyle Bulahan Servida
Gender: Male
Age: 15 days old
Admission: April 20, 2009
Admitting Diagnosis: Sepsis

Nursing Care Plan

ASSESSMENT

Objective

  • Temp of 35oC
  • cool, clammy skin
  • pallor
  • AOG of 30 weeks
  • poor skin turgor
  • poor sucking reflex

NURSING DIAGNOSIS

Dx #1 Ineffective Thermoregulation related to absence of brown adipose tissure secondary to prematurity as evidence by fluctuations in body temperature below the normal range.
Dx #2 Ineffective Feeding Pattern related to prematurity
Dx #3 Deficient Fluid Volume related to poor intake due to poor sucking secondary to prematurity

PLANNING

At the end of 8 hours nursing intervention
Plan #1 the mother will learn techniques that will help maintain the body temperature of the baby within normal limits
Plan #2 the mother will learn techniques that will help improve the weight of the baby
Plan #3 the baby will improve his intake and be free of signs of dehydration

INTERVENTION

Independent Rationale
Monitor vitals signs Serves as a baseline information and any changes may indicate worsening of infants condition
Assisted mother to wrap the baby with warm blankets and put knit cap on infants head Help keeps the baby warm
Encouraged mother to provide clothing for the baby that is appropriate ti his age, size and weather Appropriate clothing gives additional warmth to the baby and prevents heat loss
Warmed objects coming in contact with infant’s body, such as stethoscopes and thermometer Decreases loss of heat
Change clothing or bed linens when wet. Keep infant’s head covered Decreases evaporative losses
Provide calm, quiet, and non-stimulating environment while feeding Excessive stimulation may interfere with feeding
Position infant on right side or prone, with head of mattress elevated 30 degrees Facilitates gastric emptying and prevents reflux
Encourage/support mother’s efforts to pump and collect own breast milk Breast milk is easy to digest
Kept side rail up For infants security
Collaborative Rationale
IVF monitored and regulated as prescribed For hydration and glucose

Provided Health Teaching

  • Activity
    • Techniques / procedures for feeding
    • Monitoring of infants weight
  • Hygiene
    • Importance of proper handwashing
    • Cleaning of nipples before and after breastfeeding
  • Diet
    • Discuss the advantages of breastfeeding
    • Emphasize importance of well-balanced, nutritious food intake for mother

EVALUATION

After the 8 hours nursing intervention
Plan #1 Goal Met the mother learned ways to keep her baby warm and help maintain the infant's temperature
Plan #2 Goal Met the mother learned ways that will help her to improve the weight of her baby
Plan #3 Goal Partially Met the infant's sucking reflex improve but there is still some sign of dehydration like poor skin turgor

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