NURSING DIAGNOSIS

DESIRED OUTCOMES

ACTIONS/INTERVENTIONS

EVALUATION

Risk factors may include

Immature immune response, fragile skin, invasive procedures

(prematurity)

Possibly Evidenced by

presence of signs/symptoms establishes an actual diagnosis such as clinical blood tests or observing redness, swallowing, sensitivity over the area of invasive ways

RISK FOR INFECTION

The neonate will

Be free of (systemic or local) signs of infection, for example temperature instability, lethargy, respiratory distress, purulent drainage/secretions

Parents will

Verbalize measures to decrease infection in her newborn by end of shift

Determine gestational age of fetus, using Dubowitz criteria.

[Delivery prior to 28 - 30 weeks’ gestation increases infant’s susceptibility to infection, because of reduced ability of WBCs to destroy bacteria, reduced transferof IgG (IgG is transported across the placentaprimarily in the third trimester)

Institute aseptic precautions, especially handwashing, around infant.

Teach parents about infectious process, including routes, pathogens, environment andhost factors. Include specificaspects of prevention:

•Wash hands often, especially beforehandling infant or after changing her diaper

•Do not allow sick friends or family tointeract with infant

Perform care of umbilical cord.

Provide breast milk for feeding, if available since breast milk contains IgA, macrophages, lymphocytes, and neutrophils, which provide some protectionfrom infectio

Baby T’s situation had a crucial risk concerning infection due to being 27 weeks’gestation age but remained free from infection.