Neonatal Sepsis is an infection in the blood that spreads throughout the body and occurs in a neonate. Here are 5 Neonatal Sepsis Nursing Care Plans.
Neonatal Sepsis is also termed as Neonatal Septicemia and Sepsis Neonatorum.
Neonatal Sepsis has 2 types: The one that is seen in the first week of life is termed as Early- onset sepsis and most often appears in the first 24 hours of life.
The infection is often acquired from the mother. This can be cause by a bacteria or infection acquired by the mother during her pregnancy, a Preterm delivery, Rupture of membranes (placenta tissue) that lasts longer than 24 hours, Infection of the placenta tissues and amniotic fluid (chorioamnionitis) and frequent vaginal examinations during labor. The second type or the Late-onset Sepsis is acquired after delivery. This can be cause by contaminated hospital equipment, exposure to medicines that lead to antibiotic resistance, having a catheter in a blood vessel for a long time, staying in the hospital for an extended period of time.
Signs and symptoms of Neonatal Sepsis includes but is not limited to: body temperature changes, breathing problems, diarrhea, low blood sugar, reduced movements, reduced sucking, seizures, slow heart rate, swollen belly area, vomiting, yellow skin and whites of the eyes (jaundice). Possible complications are disability and worst is death of the neonate.
This post has 5 Neonatal Sepsis Nursing Care Plans
1. Hyperthermia - Neonatal Sepsis Nursing Care Plans
NDx: Hyperthermia related to inflammatory process/ hypermetabolic state as evidenced by an increase in body temperature, warm skin and tachycardia
Due to the presence of an infectious agents, 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 an increased heat conservation (Vasoconstriction) and increased heat production which results to fever.
| Assessment | Planning | Intervention | Rationale | Expected Outcome |
| Subjective: May manifest:
Objective: The patient may manifest one or more of the following:
| 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 Long Term: After 3 days of NI, pt will still maintain normal core temperature as evidenced by normal vital signs and normal laboratory results.
| Independent 1. Monitor neonate’s condition. 2. Monitor Vital signs 3. Provide TSB Interdependent 4. Ensure that all equipment used for infant is sterile, scrupulously clean. Do not share equipment with other infants Dependent 5. Administer Anti-pyretics as ordered | 1. To determine the need for intervention and the effectiveness of therapy. 2. To have a baseline data 3. Helps in lowering down the temperature 4. this would prevent the spread of pathogens to the infant from equipment 5. aids in lowering down temperature | The patient shall maintain normal core temperature as evidenced by normal vital signs and normal laboratory results. |
2. Fluid Volume Deficit - Neonatal Sepsis Nursing Care Plans
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
Assessment | Planning | Intervention | Rationale | Expected Outcome |
| Subjective: Objective: The patient may manifest one or more of the following:
| 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. | 1. Monitor and record vital signs 2. Note for the causative factors that contribute to fluid volume deficit 3. Provide TSB if patient has fever 4. Provide oral care by moistening lips & skin care by providing daily bath 5. Administer IV fluid replacement as ordered 6. Administer antipyretic drugs if patient has fever as ordered | 1. To note for the alterations in V/S (decreased BP, Increased in PR and temp) 2. To assess what factor contributes to fluid volume deficit that may be given prompt intervention. 3. To decrease temperature and provide comfort 4. To prevent injury from dryness 5. replaces fluid losses 6. to reduce body temperature | The patient shall 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. |
3. Ineffective Tissue Perfusion - Neonatal Sepsis Nursing Care Plans
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.
| Assessment | Planning | Intervention | Rationale | Expected Outcome |
| Subjective: Objective: The patient may manifest one or more of the following:
| 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 edema Long 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. | Independent 1. Monitor neonate’s condition. 2. Monitor Vital signs 3. Note quality and strength of peripheral pulses 4. Assess respiratory rate, depth, and quality 5. Assess skin for changes in color, temperature and moisture 6. Elevate Head of Bead 7. Elevate affected extremities with edema once in a while Interdependent 8. Provide a quiet, restful atmosphere Dependent 9. Administer oxygen as ordered | 1. To determine the need for intervention and the effectiveness of therapy. 2. To have a baseline data 3. To asses pulse that may become weak or thready, because of sustained hypoxemia 4. 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. 5. To assess for compensatory mechanisms of vasodilation 6. To promote circulation /venous drainage 7. To reduce edema 8. Conserves energy and lowers O2 demand 9. To maximize O2 availability 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 |
4. Interrupted Breastfeeding - Neonatal Sepsis Nursing Care Plans
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 breast fed the baby continuously due to their separation.
| Assessment | Planning | Intervention | Rationale | Expected Outcome |
| 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 sustain lactation until breastfeeding is initiated Long 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. | 1. Assess mother’s perception and knowledge about breastfeeding and extent of instruction that has been given. 2. Give emotional support to mother and accept decision regarding cessation/ continuation of breast feeding. 3. Demonstrate use of manual piston-type breast pump. 4. Review techniques for storage/use of expressed breast milk 5. Determine if a routine visiting schedule or advance warning can be provided 6. Provide privacy, calm surroundings when mother breast feeds. 7. Recommend for infant sucking on a regular basis 8. Encourage mother to obtain adequate rest, maintain fluid and nutritional intake, and schedule breast pumping every 3 hours while awake | 1. To know what the mother already knows and needed to know. 2. To assist mother to maintain breastfeeding as desired. 3. aid in feeding the neonate with breast milk without the mother breastfeeding the infant. 4. To provide optimal nutrition and promote continuation of breastfeeding process 5. So that infant will be hungry/ ready to feed 6. To promote successful infant feeding 7. Reinforces that feeding time is pleasurable and enhances digestion. 8. 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. |
5. Risk for Impaired Parent/Infant Attachment – Neonatal Sepsis Nursing Care Plans
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.
| Assessment | Planning | Intervention | Rationale | Expected Outcome |
| 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. | 1. Interview parents, noting their perception of situation and individual concerns 2. Educate parents regarding child growth and development, addressing parental perceptions 3. Involve parents in activities with the newborn that they can accomplish successfully 4. Recognize and provide positive feedback for nurturant and protective parenting behaviors | 1. To know what the parents feelings about the situation. 2. Helps clarify realistic expectations 3. Enhances self-concept 4. Reinforces continuation of desired behaviors | the parents shall be able to have a mutually satisfying interactions with their newborn. |
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