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TONDO MEDICAL CENTER- PEDIA WARD Nursing Care Plan Patient: Baby A- 8 days old (Current dx: Sepsis)

Assessment Nursing Diagnosis Hyperthermia related to inflammatory process secondary to disease process as manifested by increased temperature Inference Goal Intervention Date of Confinement: September 17, 2009 Rationale Evaluation

Subjective Data:  Patient is incapable of verbal communication.  Mother verbalized Mainit ang anak ko. Objective Data:  Body temperature above normal range (38.3C, axillary)  Tachypnea (73 breaths/min)  Tachycardia (160 beats/min)  Warm, flushed skin  Facial grimacing, crying

Sepsis Pooling of bacteria in the blood stream Inflammatory process initiated Vascular changes
(Vasodilation, capillary permeability, blood flow)

After 2 hours of effective nursing intervention, the patients temperature will return to normal as manifested by: a. Temperature within normal range (36.4 to 37.2 C, axillary temperature for infants) b. Relief of signs of discomfort such as grimacing and crying c. Other vital signs within normal range
 for newborns-neonate: RR: 20-40 breaths/min PR (apical): 75-155 beats/min

1. Establish rapport with the patient and guardian.

1. Establishing rapport promotes patient and guardians cooperation in the nursing care.

2. Monitor temperature. 2. Monitoring helps the nurse to identify the development of the patients temperature. 3. Monitor other vital signs such as respiratory and pulse rates. 3. Hyperventilation may initially be present. Dysrhythmia may be due to direct effects of hyperthermia on blood and cardiac tissue.

After 2 hours of effective nursing intervention, the patients temperature returned to normal as manifested by: d. Temperature within normal range (36.4 to 37.2 C, axillary temperature for infants) e. No signs of discomfort such as grimacing and crying

Cellular changes
( leukocytes, release of chemical mediators)- as a compensatory mechanism

Local effects (erythema, warmth, swelling, pain, impaired functioning) Systemic effects (FEVER, malaise)

4. Monitor ventilatory effort.

4. Ventilatory effort f. Other vital signs may be impaired due within normal to hypermetabolic range state and possible  For newbornsseizures. 5. Fluids and electrolytes may be loss due to dehydration.
neonate: RR: 20-40 breaths/min PR (apical): 75-155 beats/min

5. Monitor/record all sources of fluid loss such as urine, vomiting, diarrhea,

wounds, insensible losses. 6. Administer antipyretics as ordered. 6. To reduce fever. Do not give aspirin and related drugs as it may cause Reyes syndrome. 7. Promotes heat loss by radiation and conduction.

7. Promote surface cooling by means of undressing or wearing light-weight clothing. 8. Perform tepid sponge bath. Avoid too much exposure of infant as it may cause chills. 9. Place a cool cloth (not ice) on the infants forehead. 10. Promote fluid intake; Administer replacement fluids and electrolytes.

8. Promotes heat loss by evaporation and conduction.

9. Gives a cooling sensation; comforting to the infant. 10. To replace lost fluids and to support circulating volume and tissue perfusion. 11. Reduces metabolic demand/ oxygen consumption.

11. Maintain bed rest.

12. Administer 12. To treat underlying medications such as cause.(ex: infection) antibiotic as ordered.

13. Teach guardian not 13.Drugs may cause to give the patient serious adverse OTC drugs or effects on the infant; aspirin. Follow may impair renal medications and hepatic function prescribed by the if given on wrong physician. doses. 14. Discuss to guardian 14.To prevent the importance of dehydration. adequate fluid intake of the patient. 15. Teach guardian not 15.Covering the infant to cover the patient tightly will increase with thick clothing or the temperature blanket; attend further and does not immediately to prevent shaking or patients needs. trembling associated with high fever. Attending to the patients needs decreases discomfort.

PAMANTASAN NG LUNGSOD NG MAYNILA


(University of the City of Manila) Gen. Luna cor. Muralla Sts. Intramuros, Manila

College of Nursing

NURSING CARE PLAN ON: SEPSIS/SEPTICEMIA


(ACTUAL)
RAZEL G. CUSTODIO BSN III-3 TMC-PEDIA WARD PROF. MANUELA TIRAZONA Clinical Instructor