Anda di halaman 1dari 2

NURSING CARE PLAN

ASSESSMENT
Objective: - Umbilical cord still fresh - Covered in dirty blanket

NURSING DIAGNOSIS
Risk for infection related to fresh umbilical cord secondary to inadequate secondary defence.

RATIONALE
A newborn does not yet have a mature immune system and is often unable to mount an effective immune response. Newborns are generally protected by the antibodies they receive through the placenta before birth and through their mother's breastmilk after birth. These antibodies will be the same ones that are circulating in the mother's system, which will include antibodies to the microorganisms in the mother's home environment and other places she frequents.

OBJECTIVES
Short-term goal: Within 5-10 mins. 1. Client will have his/her cord clean.

NURSING INTERVENTIONS
Bathe the baby -

RATIONALE
To decrease the microorganism around the fresh umbilical cord and the body of the baby to avoid infection To reduce the microorganism that will cause infection.

EVALUATION

Long-term goal: Within 2-3 hours 1. The client will be free from infection.

Clean the cord with betadine solution

Keep the cord stump, clean, dry and exposed to air.

So that the stump will be free from infection and it will easily fall off.

Properly put a diaper on the baby, and leave a space for the stump

The cord stump can get irritated to friction.

Have a scheduled time on bathing the baby and cleaning the stump.

To ensure cleanliness and free from infection.

Anda mungkin juga menyukai