NURSING CARE PLAN

Nursing Problem/Cues Analysis Goal/Objectives Nursing Interventions Rationale Evaluation

Risk for Injury related Preterm infants are After 1 week of nursing Effectiveness
to prematurity and highly susceptible to intervention, the
Were the parents of the
sepsis. early sepsis and patient will be free of
patient able to state
pneumonia with RDS, injury. newborn care, including
S> since preterm delivery jaundice in less than 10
- Patient was born at has been increasingly a. After 30 minutes of 1. Instruct parents a. To enhance parent- minutes?
home by midwife. shown to be associated discussion, the parents regarding newborn infant interaction and Yes__NO__Why?
- “Sa bahay lang ako with a maternal of the patient will be care, including acquaintance.—
Wong’s Nursing Care of Were the parents of the
nanganak.” bacterial pathogen. able to state newborn jaundice—the
patient able to
- Mother verbalized ELBW and VLBW care, including jaundice appearance, Infants and Children, 8th
demonstrate newborn
that the patient was infants are also high in less than 10 minutes. significance, Ed. pg. 324
care correctly?
expected to be born in susceptible to fungal importance of follow- Yes__No__
August. and viral infections. up visit to practitioner Why?
-“Hindi siya Because the infant’s within 2-3 days of
Was the patient’s skin
masyadong dumidede poor response to discharge, feeding
free from injury and
kasi madalas siyang pathogenic agents, methods, and noting damage?
tulog.” there is usually no local stooling and voiding. Yes__NO__Why?
- Grandmother inflammatory reaction
verbalized the patient at the portal of entry to b. After 1 day of 2. Demonstrate b. To enhance parent- Were the parents of the
not receiving Vitamin signal an infection. nursing intervention, newborn care. infant interaction and patient able to provide
acquaintance.— parental supervision?
K after birth. Sepsis refers to a the parents of the
Wong’s Nursing Care of Yes__No__Why?
generalized bacterial patient will be able to
Infants and Children, 8th
O> infection in the demonstrate newborn Were the parents of the
Ed. pg. 324
-yellowish bloodstream. Sepsis care correctly. patient able to perform
discoloration of skin. can be acquired safety precautions
c. Skin and tissues are appropriately?
-poor sucking reflex prenatally across the c. After nursing 3. Handle infant
fragile and are at risk Yes__No__Why?
-green stool, twice a placenta from the intervention, the gently.
for damage. –Nursing
day with urine; 3 oz. maternal bloodstream patient’s skin will be Care Plans by Marilynn Was the patient able to
each or during labor from free from injury and E. Doenges, 8th Ed. pg. have vital signs within
-use of bililight 12 ingestion or aspiration damage. 899 normal range?
hours/day since of infected amniotic Yes__No__Why?
admission. fluid. The nonspecific,
-weak cry early signs are
-pale, dry lips hypothermia, poor
-T = 35.8 C feeding, diarrhea or
(Hypothermic) decreased stool, and
jaundice. An excessive
level of accumulated
bilirubin in the blood is
characterized by
jaundice. Unconjugated
bilirubin is highly toxic
to neurons; therefore
an infant with severe
jaundice is at risk of
developing bilirubin
encephalopathy, which
may result to
Kernicterus.
Unconjugated and
elevated bilirubin
crosses the blood-brain
barrier in neonates,
causing the infant to
have increased
permeability of the
blood-brain barrier to
unconjugated bilirubin
and, thus, potential
irreversible damage.
Wong’s Nursing Care of Infants
and Children, 8th Ed Vol.1 pg
321-322
d. After nursing 4. Encourage parents d. Permits monitoring Was the patient able to
intervention, the of patient to provide of child’s well-being receive appropriate
medications?
parents of the patient appropriate level of and allows for timely
Yes__No__Why?
will provide parental supervision, with intervention. –Nursing
supervision. nurse’s assistance. Care Plans by Marilynn Were the parents of the
E. Doenges, 8th Ed. pg. patient able to
899
demonstrate safety
needs and injury
prevention in home
e. After 1 day of 5. Initiate safety e. Preventing injuries setting?
nursing intervention, precautions as and complications is a Yes__No__Why?
the parents of the individually prime responsibility of
patient will be able to appropriate, such as parents and Were the parents of the
perform safety infection precaution. caregivers. –Nursing Care
Plans by Marilynn E. Doenges,
patient able to verbalize
precautions 8th Ed. pg. 899 desire to attend
appropriately. community educational
programs?
f. After 1 day of nursing 6. Review home f. Promotes a safe Yes__No__Why?
intervention, the situation for safety environment. –Nursing
parents of the patient hazards. Ascertain Care Plans by Marilynn E. Efficiency
Doenges, 8th Ed. pg. 899
will be able to parent knowledge of
Were resources
demonstrate safety safety needs and
available to the nurse
needs and injury injury prevention in and client?
prevention in home home setting. Yes__No__
setting. Why?
g. After 1 day of 7. Monitor vital signs g. To promote physical Appropriateness
nursing intervention, per unit protocol or at care of newborn and
decrease parents’ Were interventions
the patient will be able least every 8 hours. appropriate to client
to have vital signs that Report signs of poor anxiety related to
situation?
are within normal transition to home care. –Wong’s Yes__No__
Nursing Care of Infants and
range. extrauterine life. Children, 8th Ed. pg. 324 Why?
h. After nursing 8. Monitor medication h. Provides for Acceptability
intervention, the administration closely, effective therapeutic
Were all interventions
patient will be able to especially dosage management,
acceptable to the client?
receive appropriate measurements and prevents overdose, Yes__No__
medications. conversions. Use and reduces risk for Why?
pediatric toxic reactions.
concentrations of –Nursing Care Plans by Adequacy
Marilynn E. Doenges, 8th Ed.
medications when pg. 899
Were the numbers of the
available.
interventions enough to
solve the health
i. After nursing 9. Refer to community i. Can provide problems?
intervention, the education programs additional
patient’s parents will and resources, such as opportunities for Yes__No__
be able to verbalize Family Effectiveness Why?
improving parenting
desire to attend Training. skills and obtaining
community educational necessary equipment.
programs. –Nursing Care Plans by
Marilynn E. Doenges, 8th Ed.
pg. 899