ASSESSMENT SUBJECTIVE CUES: • Mother:
NURSING DIAGNOSIS Risk for infection related to inadequate primary defenses (broken skin specifically referring to exposed umbilical cord)
RATIONALE
GOALS AND OBJECTIVES The stump of the Goal: umbilical cord is an After one day of excellent medium nursing for bacterial intervention, the growth. Therefore, mother will be able without proper cord to give proper cord care, the child is care for the baby. susceptible to cord infection. Objectives: After one hour of intervention, the mother will learn how to give proper cord care by: 1. Giving the proper and hygienic method of cleaning the remaining umbilical cord.
INTERVENTION
Diagnostic: 1. Note risk factors for occurrence of infection.
2. Assess and document skin conditions around the base of the umbilical cord.
RATIONALE
1. Identifying the area of which serves as a beneficial environment for bacterial growth will help the mother recognize areas that will need thorough cleaning. 2. Assessing the skin conditions around the base of the umbilical cord will enable the mother
EVALUATION
3. Note signs and symptoms of fever. Therapeutic: 1. Stress proper hand washing techniques. 2. Proper application of betadine and alcohol on the tip of the cord. Health Education: 1. Instruct client how to protect the integrity of the skin and prevent spread of infection around the base of the umbilical cord.