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Nursing Diagnosis Interventions for Sepsis

1. Risk for infection (progression from sepsis to septic shock) related to the development of opportunistic infections.
  • Give isolation / monitor visitors as indicated.
  • Wash hands before and after doing the activity even when wearing gloves.
  • Limit the use of tools / invasive procedures if possible.
  • Use sterile technique.
  • Monitor the temperature / temperature increase on a regular basis
  • Observe the chills.
  • Monitor the client's vital signs.
  • Collaboration with the medical team in the administration of antibiotics.

2. Hyperthermia / hypothermia related to an increase in metabolic rate, vasoconstriction / vasodilation of blood vessels.
  • Monitor the client's temperature (degrees and patterns) note chills / diaphoresis.
  • Monitor the ambient temperature / ambient temperature setting.
  • Isolation child / baby in an incubator.
  • Give compress (cold, warm) if there is an increase / decrease in temperature.
  • Note the increase / decrease in the baby's body temperature.
  • Collaboration with the medical team in laboratory tests (increased leukocytes).

3. Ineffective tissue perfusion related to decreased oxygen supply / irregular breathing.
Review of the pattern of growth or decline in the number of prenatal and amniotic fluid as detected by ultrasonography.
  • Note the type of birth and incidence of intra-partum hypoxia signaling.
  • Note the time and Apgar scores, respiratory pattern observation.
  • Assess respiratory rate, depth, effort, observation and report signs and symptoms of respiratory distress, distinguish from symptoms associated with polycythemia.
  • Auscultation of breath sounds on a regular basis.
  • Nasopharyngeal suction hose as needed, after the first oxygen supplementation.
  • Auscultation apical pulse, note the presence of cyanosis.
  • Latrogenik prevent complications related to cold distress, metabolic imbalances and insufficient calories.
Ccollaboration
  • Monitor the pulse oximeter readings.
  • Monitor laboratory tests as indicated, serum pH, blood gas analysis, and HT.
  • Give a warm and humid oxygen, provide assistance vertilasi as indicated.
  • Perform suction.
  • Avoid execution of suction that is too often.
  • Observation and review of infant response to oxygen therapy.

4. Risk for fluid volume deficit related to diarrhea, vomiting and fluid shifts from the interstitial to the vascular.
  • Monitor intake and output.
  • Measure body weight every day.
  • Monitor blood electrolyte levels, blood urea nitrogen, urine and serum osmolality, creatinine, hematocrit and hemoglobin.
  • Assess body temperature, moisture in the oral cavity, the volume and concentration of urine.
  • Give: liquid forms an interesting, unusual containers (colored cups, straws) and a game or activity (send the child to drink when the time came for the child).

5. Imbalanced Nutrition: less than body requirements related to nausea, vomiting and increased metabolism.
Assess the weight in relation to gestational age and size. Documented on a growth chart. Measure body weight every day.
  • Keep termonetral environment, including the use of incubators as indicated. Monitor the temperature of the heater baby and the environment with frequently.
  • Do it early and often feeding and proceed according to tolerance.
  • Assess tolerance to food. Note the stool color, consistency and frequency, a decrease in substance, abdominal circumference, vomiting and gastric residue.
  • Monitor input and output. Calculate caloric and electrolyte intake every day.
  • Assess the level of dehydration, note the fontanelle, skin turgor, urine specific gravity, the condition of the mucous membrane and weight fluctuations.
  • Monitor Dextrosix levels immediately after birth and regularly until serum glucose stabilized.
  • Review the signs of hypoglycemia.
Ccollaboration
  • Monitor laboratory tests as indicated
  • Give electrolyte supplements as indicated.
  • Create an intravascular access as indicated.
  • Give parenteral nutrition.
  • Discuss long-term complications of malnutrition in infants SGA and LGA infants obesity, discuss the importance of brain growth protein subs (Doenges, 2000).

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