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Assessment Nursing Diagnosis Goals & Expected Nursing Interventions Rationale for interventions Evaluation Evaluation

(Supporting data) (NANDA diagnostic statement) Outcomes (Strategies or actions for care) (Include source and page numbers) (Client’s response to
(Realistic, timed, nursing actions
measurable) & progress toward
achieving goals
& outcomes)
Subjective:
MOC states “I have no milk Ineffective Assess a feeding for proper Collect baseline data Baby L was able
because I had a c-section”; Baby will feed four technique to consume 20mL
MOC is using S&S to breastfeeding r/t times during shift, during four
supplement feedings. maternal breast supplementing with feedings
Determine effect of altered Maternal-infant response
anomaly AEB need for 20 mL of formula breastfeeding pattern on mother provides important
supplemental feedings per feed and infant by spending 30 information in determining
Objective:
and no observable minutes talking with mother. how serious the
maternal milk Observe mother-infant breastfeeding issue is. This
Baby L is consuming 20-30 production interactions and maternal will dictate how to approach
mL of formula per feeding; feelings expressed. the problem and promote
MOC’s breasts are very realistic follow-up.
tubular in shape, very little
Measure I/Os
mammary tissue present;
cannot express milk with
pump. Baby’s weight has
remained constant since birth
(6 lb, 5 oz)

Assessment Nursing Diagnosis Goals & Expected Nursing Interventions Rationale for interventions Evaluation Evaluation
(Supporting data) (NANDA diagnostic Outcomes (Strategies or actions for care) (Include source and page (Client’s response
(Realistic, timed, numbers) to nursing actions
statement) measurable) & progress toward
achieving goals
& outcomes)
Subjective:
Risk for infection R/T Baby will remain free Monitor vital signs every 4 hours Provides baseline and allows Baby L remained
maturational factors and from infection for for quick identifications of any free from infection
duration of hospital deviations that could indicate
immature immune system stay. infection
Institute aseptic precautions,
especially handwashing, around Protects baby from pathogens
infant.
Objective:
Subjective: Baby is Assess infant’s Infants lack mature
calm, soothes easily, Risk for Infant will maintain its temp each hour thermoregulation. Goal Met: Baby
does not appear imbalanced body temperature Temps too high or too L’s temp. remains
uncomfortable between 97.0 and 99.0F low can disrupt acid- WNL for entire
body base balance, causing
temperature r/t for entire shift shift
seizures or shock.
extreme of age If temp is above
(newborn status) 101F, take Infants are at risk for
measures to bring febrile seizures r/t
temp to normal immature
range: thermoregulation and
Objective: Baby L’s o Administe must be safeguarded
axilla temp: 98.1 F; skin against further sequelae.
r
warm and dry
antipyretic Signs of neonatal
s as seizures include:
ordered
o Monitor
• Repetitive sucking
and
• Repeated
document
extending of the
related tongue
symptoms • Continuous
with chewing
specific • Continuous
regard to drooling
febrile • Long pauses in
seizures breathing (apnea)
• Rapid eye
movements
• Blinking/fluttering
of eyelids
• Fixation of gaze to
one side
• Body aligned to
one side
• Pedaling/stepping
movements of legs
• Paddling/rowing
movements of
arms
• Rapid muscle jerks

If temp is < 97.0F,


take measures to Young infants cannot
bring temp to initiate compensatory
normal range: regulation of
o p temperature and can
l become septic at body
a temps below 97.0F
c
e Infants can become
dehydrated under
SUBJECTIV Altered After 24hrs *INDEPENDENT: After 24hrs,
E: nutrition: of 1. Assess presence of -Determines the pt was seen
“Wala pa less than continuous reflexes associated appropriate feeding beside
na siya'y body nursing with feeding (i.e method for the infant. mother,
kaon ”, as requiremen intervention, swallowing, sucking & exhibiting
pt SO ts r/t to pt will coughing) good suck-
stated. small demonstrate and-swallow
stomach steady wt 2. Instill breast milk -Too rapid entry of reflex, and
capacity & gain in a or formula slowly over feeding into stomach showed to
OBJECTIVE prematurity normal 20min @ a rate of may cause rapid rebound have added
: as evidenced curve (@ 20ml/min. response with 10g.
by weak least 20- regurgitation, increased
-found feeding 30g/day) risk of aspiration & abd
patient reflexes & and also distension all of which
lying on NPO status. maintained compromises respi
bed supine growth. 3. Initiate intermittent status.
with IV D5 or tube feedings as
-small for indicted. -Gavage feedings may be
gestational necessary to provide
age adequate nutrition in
- wt= infant who has a poorly
coordinated suck-and-
swallow reflex or who
4. Position infant on becomes fatigued during
right side or prone oral feedings.
with HOB elevated @
30 degrees. -Facilitates gastric
emptying & prevents
*COLLABORATIVE: reflux.
1. Feed as frequently
as indicated based on
infant’s wight & -Infants <1250g are
estimated stomach usually fed q 2hrs;
capacity. infants b/w 1500 &
1800g are fed q 3hrs.
2. Administer
supplemental vitamins
& minerals, esp Vit A, -Replaces low nutrient
B, C, D, & E and Iron stores to promote
as prescribed. adequate nutrition &
reduce risk on infection.
SUBJECTIVE Ineffective After 24hrs *INDEPENDENT:
: thermoreg of thorough 1. Assess V/S (esp T) -Hypothermia After 24 hours Goal was
“Naa man to ulation r/t nursing predisposes infant to of close met, left
siya’y to intervention cold stress, utilization of monitoring, patient lying
hilanat prematurity , pt will nonrenewable brown fat infant was able on bed
gahapon, ny as exhibit stores. Hyperthermia to establish afebrile &
akaron wala evidenced thermal causes further normothermia with a
naman.”, as by poor homeostasis 2. Place infant in a respiratory depression and had T= temperature
pt. SO flexion & appropriate warmer, isolette, instead of increased RR, 36.5 C. appropriate
verbalized. lack of for age = incubator, or open bed leading to apnea & for age.
subcutaneo 36.5-37 C with radiant warmer or reduced O2 uptake.
us fat. (axillary) open crib wherein
OBJECTIVE: infant also has -Maintain thermoneutral
appropriate clothing. environment, helps
T=35 C prevent cold stress.

-tachypnea 3. Use heat lamps


during certain -Decreases heat loss to
procedures & warm the cooler environment
objects coming in of the room.
contact with the
infants body such as -Helps prevent seizures
clothing. associated with
hyperthermia and
*COLLABORATIVE: corrects acidosis which
1. Provide or may occur on both hypo
administer meds as & hyperthermia.
prescribed.
Assessment Nursing Nursing Goal Nursing Intervention Rationale Outcome Criteria Actual
Diagnosis Evaluation

SUBJECTIV Impaired After 24hrs *INDEPENDENT: -Tachypnea indicates After 24 hrs of Goal met.
E: Gas of nursing 1. Assess respiratory respiratory distress esp thorough nsg. Seen pt. lying
exchange intervention: status, noting signs of when respi are Intervention, on bed
As r/t patient will respiratory distress >75cpm/min after the patient was without the
verbalized immature be (e.g., tachypnea, nasal first 5 hours of life. able to breathe oxyhood.
by the pt pulmonary gradually flaring, grunting, Expiratory grunting normally
SO: “naa functioning weaned to retractions, rhonchi, or represents attempt to without
na’y oxygen room air and crackles). maintain alveolar supplemental
nga breathe expansion; nasal flaring oxygen.
nakataod sa normally is a compensatory
iya.” without mechanism to increase
supplementa diameter of nares &
l oxygen. 2. Assess skin color for increase Oxygen intake.
dev’t of cyanosis.

3. Promote rest,
OBJECTIVE: minimize stimulation -Lack of Oxygen will
-dyspnea & energy expenditure. result in cyanosis.
noted
-RR= *COLLABORATIVE: -to decrease the
-rapid, equal 1. Monitor metabolic rate & Oxygen
chest lab/diagnostic studies consumption.
expansion as appropriate.

-Reveals & prevents any


further complications.