Patient: Baby Girl Ararao Age: 1 day

Student Assigned: Monique David Clinical Instructor: Ms. Karen Louela Rint, RN

Diagnosis: R/o Aspiration Pneumonia; Multiple Congenital Anomalies

Risk for aspiration r/t impaired swallowing secondary to absent soft palate I

Cues

Nursing Diagnosis

Background Knowledge

Short Term Goal

Long Term Goal

Intervention

Rationale

Evaluation

S- ³Kahapon, nung pinainom naming

Risk for

At risk for entry

Within

To facilitate

>

Assessed > provide basis Goal

Met

aspiration r/t of impaired gastrointestinal

the shift, the patient will be able to or maintenance of a supply of oxygen to

rate and depth for

evaluating The patient of was able to establish a patent respiratory

siya ng gatas. Bigla siyang Sabi ni nangitim. Doktora

of respirations adequacy and type of ventilation

swallowing secretions, secondary oropharyngeal to absent secretions,

breathing pattern

pumunta sa baga ni baby yung gatas kasi wala siyang ngalangala´ as

maintain all body cells patent airway.

soft palate solids or fluids into tracheobronchial passages

> Auscultated > for evaluation airway and chest character breath sounds > of a normal

respiratory

verbalized by the mother

Bedside >provide comfort pattern as to patient evidenced

care provided

signs clammy skin may hypoxia indicate decreased oxygen supply to the peripheral arteries. Cyanosis indicate respiratory distress may > Elevated > to promote lung expansion head of bed >Placed below > to maintain a droplight body heat .by absence O5 LPM Cleft noted Microglossia palate c O2 line at > V/S taken >serve as of cyanosis other of and recorded baseline data of and every 1 hour patient. especially temperature and color Cold.

through radiation >Maintained NPO status >to eliminate cause of aspiration > I&O Monitored > To determine fluid retention. and nutrition of the newborn >Administered >increases supplemental available O2 for oxygenation at body¶s 5 LPM through consumption a headbox >Administer meds >Pharmacological as management: . dehydration.

indicated .