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NDx: Hyperthermia related to inflammatory process/ hyper metabolic state as evidenced by an increase in body temperature, warm skin and tachycardia
Due to the presence of an infectious agent, stimulation of the monocytes triggers the release of the pyrogenic cytokines that stimulate anterior hypothalamus which results in elevated thermoregulatory set point that leads to increased heat conservation (Vasoconstriction) and increased heat production which results to fever.
Subjective: May manifest:
The patient may manifest one or more of the following:
Temperature above normal level (36 oC)
Skin warm to touch
Presence of tachycardia (above 160 bpm)
Presence of tachypnea (above 60 bpm)
Short-term:After 30 minutes of nursing intervention the patient will maintain normal core temperature as evidenced by vital signs within normal limits and normal WBC level
After 3 days of NI, pt will still maintain normal core temperature as evidenced by normal vital signs and normal laboratory results.
Monitor neonate’s condition.
Monitor Vital signs
Ensure that all equipment used for infant is sterile, scrupulously clean. Do not share equipment with other infants
Administer Anti-pyretics as ordered
To determine the need for intervention and the effectiveness of therapy.
To have a baseline data
Helps in lowering down the temperature
this would prevent the spread of pathogens to the infant from equipment
aids in lowering down temperature
Fluid Volume Deficit NDx: Fluid volume deficit related to failure of regulatory mechanism
Fluid volume deficit, or hypovolemia, occurs from a loss of body fluid or the shift of fluids into the third space one factor includes a failure of the regulatory mechanism of the newborn specifically hyperthermia
Subjective:Objective:The patient may manifest one or more of the following:
decreased urine output
increased urine concentration
increased pulse rate (above 160 bpm)
increased body temperature (above 36 oC)
decreased skin turgor
dry skin/ mucous membranes
Short-term:After 3 hours of nursing intervention, the patient will be able to maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor and prompt capillary refill and resolution of edema.Long Term:
After a couple of days the patient will still be able to maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor and prompt capillary refill and resolution of edema.
Monitor and record vital signs
Note for the causative factors that contribute to fluid volume deficit
Provide TSB if patient has fever
Provide oral care by moistening lips & skin care by providing daily bath
Administer IV fluid replacement as ordered
Administer antipyretic drugs if patient has fever as ordered
To note for the alterations in V/S (decreased BP, Increased in PR and temp)
To assess what factor contributes to fluid volume deficit that may be given prompt intervention.
To decrease temperature and provide comfort
To prevent injury from dryness
replaces fluid losses
to reduce body temperature
The patient shall be able to maintain
Ineffective Tissue Perfusion
NDx: Ineffective tissue perfusion related to impaired transport of oxygen across alveolar and on capillary membrane Since the body of the newborn is unable to compensate to the imbalances of the inflammatory response related to his condition the body tends to “hyperdrive” causing an inadequate oxygen in the tissues or capillary membrane leading to poor perfusion.
skin or temperature changes
Inadequate urine output
Short-term:After 3 hours of nursing intervention the patient will demonstrate increased perfusion as evidenced by warm and dry skin, strong peripheral pulses, normal vital signs, adequate urine output and absence of edemaLong Term:
After 3 days of NI, pt will maintain adequate perfusion AEB stable VS, warm and dry skin, absence of edema, adequate urine output and strong peripheral pulses.
Monitor neonate’s condition
Note quality and strength of peripheral pulses
Assess respiratory rate, depth, and quality
Assess skin for changes in color, temperature and moisture
Elevate Head of Bead
Elevate affected extremities with edema once in a while
Provide a quiet, restful atmosphere
Administer oxygen as ordered
To asses pulse that may become weak or thready, because of sustained hypoxemia
To note for an increased respiration that occurs in response to direct effects of endotoxins on the respiratory center in the brain, as well as developing hypoxia, stress. Respirations can become shallow as respiratory insufficiency develops creating risk of acute respiratory failure.
To assess for compensatory mechanisms of vasodilation
To promote circulation /venous drainage
To reduce edema
Conserves energy and lowers O2 demand
To maximize O2availability for cellular uptake
The patient shall demonstrate increased perfusion as evidenced by warm and dry skin, strong peripheral pulses, normal vital signs, adequate urine output and absence of edema
NDx: Interrupted breastfeeding related to neonate’s present illness as evidenced by separation of mother to infant
Since the neonate is diagnosed for having a neonatal sepsis, the baby got separated from his mother and placed on a Neonatal Intensive Care Unit for better management and care. Interrupted breastfeeding develops since the mother is unable to breastfeed the baby continuously due to their separation.
The newborn is diagnosed with a certain disease (Sepsis)
The newborn is separated from his mother
The mother unable to provide breast milk to newborn continuously
Short-term:After 3 hours of nursing intervention and health teachings the mother will identify and demonstrate techniques to sustain lactation until breastfeeding is initiatedLong Term:
After 3 days of NI, the mother shall still be able to identify and demonstrate techniques to sustain lactation and identify techniques on how to provide the newborn with breast milk.
Assess mother’s perception and knowledge about breastfeeding and extent of instruction that has been given.
Give emotional support to mother and accept decision regarding cessation/ continuation of breast feeding.
Demonstrate use of manual piston-type breast pump.
Review techniques for storage/use of expressed breast milk
Determine if a routine visiting schedule or advance warning can be provided
Provide privacy, calm surroundings when mother breast feeds.
Recommend for infant sucking on a regular basis
Encourage mother to obtain adequate rest, maintain fluid and nutritional intake, and schedule breast pumping every 3 hours while awake
To know what the mother already knows and needed to know.
To assist mother to maintain breastfeeding as desired.
aid in feeding the neonate with breast milk without the mother breastfeeding the infant.
To provide optimal nutrition and promote continuation of breastfeeding process
So that infant will be hungry/ ready to feed
To promote successful infant feeding
Reinforces that feeding time is pleasurable and enhances digestion.
to sustain adequate milk production and breast feeding process
The mother shall be able to identify and demonstrate techniques to sustain lactation and identify techniques on how to provide the newborn with breast milk.
Risk for Impaired Parent/Infant Attachment NDx: Risk for Impaired parent/ neonates Attachment related to neonates physical illness and hospitalization.
Due to the newborn’s physical illness and hospitalization, the parents may have fear on how to handle their baby since the baby is on its fragile state and needed extra care. And since he is the 1st child hospitalized in their family, the parents might still be unsure on how to take care of the baby.
Subjective: Objective: The patient may manifest one or more of the following:
Short-term: After 3 hours of nursing intervention and health teachings the mother will identify and demonstrate techniques to enhance behavioral organization of the neonate Long Term:
After discharge the parents will be able to have a mutually satisfying interactions with their newborn.
Interview parents, noting their perception of situational and individual concerns
Educate parents regarding child growth and development, addressing parental perceptions
Involve parents in activities with the newborn that they can accomplish successfully
Recognize and provide positive feedback for nurturing and protective parenting behaviors
To know what the parents feelings about the situation.
Helps clarify realistic expectations
Reinforces continuation of desired behaviors
The parents shall be able to have a mutually satisfying interactions with their newborn.a