Nursing Care Plan for Low Birth Weight - Risk for Infection

Low birth weight babies are babies born with birth weight less than 2500 grams regardless of pregnancy. Birth weight is the weight of a baby who weighed within 1 hour after birth.

The cause of LBW is very complex. LBW can be caused by pregnancy preterm, small for gestational age baby or a combination of both.

Preterm babies are babies born before 37 weeks' gestation. Most preterm infants are not ready to live outside the womb and find it difficult to start breathing, sucking, fight infection and keep the body in order to keep warm.

Low birth weight (LBW) is newborn birth weight less than 2500 grams (up to 2499 grams). Associated with the handling and life expectancy, low birth weight babies are distinguished in:

• Low birth weight 1500-2500 g birth weight.
• Very low birth weight, birth weight less than 1500 grams.
• Extreme low birth weight, birth weight less than 1000 grams.

(Prawirohardjo, 2002)

Immediate complications that can occur in infants of low birth weight among others:

• Hypothermia.
• Hypoglycemia.
• Fluid and electrolyte disturbances.
• Hyperbilirubinemia.
• Respiratory distress syndrome.
• Infection.
• Intravascular hemorrhage.
• Apnea of prematurity.
• Anemia.

Long-term problems that may arise in LBW among others:

• Developmental disorders.
• Impaired growth.
• Visual impairment.
• Hearing disorders.
• Chronic lung disease.
• The increase in the frequency of congenital abnormalities.

Nursing Diagnosis : Risk for infection related to immunological defense ineffective.

Goal: There are no signs of infection.

Expected outcomes:

• Normal temperature.
• No signs of infection.
• Leukocytes 5000-10000.

Nursing Interventions :

• Assess for signs of infection.
• Perform insulation another baby suffering from an infection at the discretion of institutions.
• Before and after handling the baby, do handwashing.
• Make sure all equipment is in contact with the baby clean and sterile.
• Prevent personal transmitted infections for no direct contact with the baby.

Rationale:

• To find early signs of infection.
• Actions taken to minimize the occurrence of infection wider.
• To prevent infection.
• To prevent infection persists in infants.

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Acute Lymphocytic Leukemia - Risk for Infection Nursing Diagnosis and Interventions

Acute lymphocytic leukemia (ALL) is a fast-growing cancer of a type of white blood cells called lymphocytes. These cells are found in the bone marrow and other parts of the body.

Acute lymphocytic leukemia (ALL) makes you more likely to bleed and develop infections. Symptoms include:

• Bone and joint pain
• Easy bruising and bleeding (such as bleeding gums, skin bleeding, nosebleeds, abnormal periods)
• Feeling weak or tired
• Fever
• Loss of appetite and weight loss
• Paleness
• Pain or feeling of fullness below the ribs
• Pinpoint red spots on the skin (petechiae)
• Swollen glands (lymphadenopathy) in the neck, under arms, and groin
• Night sweats

Note: These symptoms can occur with other conditions. Talk to your doctor about the meaning of your specific symptoms.www.nlm.nih.gov

Nursing Diagnosis for Acute Lymphocytic Leukemia : Risk for Infection related to changes in maturity of red blood cells, increased number of immature lymphocytes, immunosuppression

Goal : no infection.

Expected outcomes are:
Clients will:

• Identify the risk factors that can be reduced
• State the signs and symptoms of early infection
• No signs of infection

Nursing Interventions Acute Lymphocytic Leukemia : Risk for Infection

1. Take action to prevent exposure to known or potential sources of infection:

• Keep the protective insulation, according to institutional policy
• Maintain a careful hand washing technique
• Give good hygiene
• Limit visitors who were fever, flu or infections
• Give two times daily perianal hygiene and each bowel movement
• Limit fresh flowers and fresh vegetables
• Use the oral care protocol
• Hospitalized with neutropenic clients first.

Rational: Vigilance, minimizing client exposure to bacteria, viruses, and fungal pathogens either endogenous or exogenous.

2. Report if there are changes in vital signs
Rationale: Changes in vital signs is an early sign of sepsis, especially if there is an increase in body temperature.

3. Get culture of sputum, urine, diarrhea, abnormal blood and body secretions as recommended
Rational: The culture can confirm infection and identify the causative organism.

4. Explain the reasons for vigilance and abstinence
Rational: The culture can confirm infection and identify the causative organism.

5. Reassure the client and his family that the increased susceptibility to infection while only
Rational: granulocytopenia may persist 6-12 weeks. The notion of a temporary nature can help prevent anxiety granulocytopenia clients and their families

6. Minimize invasive procedures
Rational: certain procedures may cause tissue trauma, increased susceptibility of infection.

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Risk for Infection Nursing Care Plan for Peritonitis

Nursing Diagnosis for Peritonitis : Risk for Infection related to tissue trauma

Risk for Infection NANDA Definition: At increased risk for being invaded by pathogenic organisms

Goal: Reduce infections, improve patient comfort.


Expected outcomes:

• Increased healing in time, free of purulent drainage or erythema, no fever.
• Stated understanding of the causes of individual / risk factors.

Nursing Interventions Risk for Infection for Peritonitis

Independent:

1. Note the example of individual risk factors abdominal trauma, acute appendicitis, peritoneal dialysis.
Rational: Affects choice of interventions

2. Assess vital signs with frequent, noted no improvement or continuing hypotension, decreased pulse pressure, tachycardia, fever, tachypnea.
Rationale: Signs of septic shock, endotoxin circulation causes vasodilation, loss of fluid from the circulation, and low cardiac output status.

3. Note the change in mental status (eg, confusion, fainting).
Rational: Hypoxaemia, hypotension, and acidosis can cause irregularities in mental status.

4. Note the color, temperature, humidity.
Rational: Warm, redness, dry skin is an early sign of septicemia. Further manifestations include cold, pale skin moist and cyanosis as a sign of shock.

5. Monitor urine output.
Rational: Oliguria occurred as a result of reduced renal perfusion, the toxin in the circulation affects the antibiotic.

6. Maintain strict aseptic technique in the treatment of abdominal drain, wound incision / open, and the invasive side.
Rationale: Prevent the spread and limit the spread of infectious organisms / cross contamination.

7. Observations on wound drainage.
Rationale: Provides information about the status of infection.

8. Maintain sterile technique when the patient is placed catheters, and catheter care provided / or perineal hygiene routine.
Rasonal: Preventing the spread, limiting the growth of bacteria in the urinary tract.

9. Supervise / limit visitors and staff as needed. Provide insulation protection when indicated.
Rational: Reduce the risk of exposure to / add a secondary infection in patients who experienced immune pressure.


Collaboration:

1. Take for example / watch the results of serial blood, urine, wound cultures.
Rationale: Identifying microorganisms and assist in assessing the effectiveness of antimicrobial program.

2. Assist in the peritoneal aspiration, if indicated.
Rational: Guide to drain fluids and to identify infectious organisms so that appropriate antibiotics but can be given.

3. Prepare for surgical intervention when indicated
Rationale: Treatment of choice (curative) in acute peritonitis or local, for example a local abscess drainage, peritoneal exudate throw, throw rupturapendiks / gall bladder, cope with perforated ulcer, or bowel resection.

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