Help with Nursing DX newborn sepsis(imagine that)

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I am a 3rd semester ADN student, I have a patient that is newborn, her mother had chorionamnionitis and the baby has an elevated white count, positive CRP and is on antibiotic therapy for infection already. My instructor helped me figure out a nursing diagnoses but when I got home to NANDA, the nursing diagnosis is not in the book. She already has an infection, so I can't use risk for infection. Here was the diagnosis from my instructor:

Neonatal infection r/t increase in WBC and pyrexia secondary to maternal chorionamnionitis AEB WBC 38, temp 103.8 after delivery.

Any suggestions are greatly appreciated.

I thought about risk for injury??? UGH, I may just text my instructor.

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Maybe her temperature?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I am a 3rd semester ADN student, I have a patient that is newborn, her mother had chorionamnionitis and the baby has an elevated white count, positive CRP and is on antibiotic therapy for infection already. My instructor helped me figure out a nursing diagnoses but when I got home to NANDA, the nursing diagnosis is not in the book. She already has an infection, so I can't use risk for infection. Here was the diagnosis from my instructor:

Neonatal infection r/t increase in WBC and pyrexia secondary to maternal chorionamnionitis AEB WBC 38, temp 103.8 after delivery.

Any suggestions are greatly appreciated.

I thought about risk for injury??? UGH, I may just text my instructor.

text your instructor......find out what she is looking for.

I would look up newborn sepsis and look up chorionamnionitis. Make a list of symptoms......then look and see which ones your assessment supports.

the symptoms of sepsis in the newborn could include (my list of symptoms):

  • a low or high fever
  • rash
  • tachypnea
  • nasal flaring
  • retractions
  • grunting
  • apnea
  • cyanosis
  • pallor
  • mottling
  • tachycardia
  • hypotension
  • decreased oral intake
  • hypoglycemia or hyperglycemia
  • lethargy
  • jitteriness
  • irritability
  • bulging fontanels
  • increased or decreased muscle tone
  • jaundice
  • petechiae
  • purpura

  • then write interventions/care plan symptoms present.

    for example....hyperthermia I am feeling generous.....;)

Hyperthermia

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.

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[TD]Assessment[/TD]

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[TD]Subjective: May manifest:

  • Irritability
  • Weakness
  • Objective:
  • The patient may manifest one or more of the following:
  • Temperature above normal level (36 oC)
  • Skin warm to touch
  • Presence of tachycardia (above 160 bpm)
  • Presence of tachypnea (above 60 bpm)
  • WBC elevated

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[TD]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 levelLong Term:After 3 days of NI, pt will still maintain normal core temperature as evidenced by normal vital signs and normal laboratory results.[/TD]

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  1. Monitor neonate’s condition.
  2. Monitor Vital signs
  3. Provide TSB
  4. Ensure that all equipment used for infant is sterile, scrupulously clean. Do not share equipment with other infants
  5. Administer Anti-pyretics as ordered

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  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

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[TD]The patient shall maintain normal core temperature as evidenced by normal vital signs and normal laboratory results.[/TD]

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That is what I started working on after I posted this. Thank you so much, that helps a lot!

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Specializes in NICU, PICU, PACU.

Can I say that the baby's temp is related to mom's temp after delivery and we so not consider that a fever. I wouldn't use pyrexia since it is pretty rare in neonates. Go with the labs. Also don't use the Tylenol, if the baby is pretty new we don't use it.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Can I say that the baby's temp is related to mom's temp after delivery and we so not consider that a fever. I wouldn't use pyrexia since it is pretty rare in neonates. Go with the labs. Also don't use the Tylenol, if the baby is pretty new we don't use it.
You sure can neonates are not my niche....I was going by book alone.:)
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