XIV.

PROBLEM LIST

A) Actual Problems

Problem No. Nursing Diagnoses Date Identified

1 Imbalanced Nutrition January 10, 2020
2 Impaired Attachment January 10, 2020
3 Impaired Skin Integrity January 9, 2020

B) Potential Problems

Problem No. Nursing Diagnoses Date Identified

1 Risk for Aspiration January 9, 2020
2 Risk for Hypothermia January 9, 2020
XV. NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

OBJECTIVE: Imbalanced nutrition: Short Term Goal: Independent:  The patient is

less than body In 4 hours, the  Assess current  To identify gaining weight
 Absence of sucking requirements related to caretakers will weight compared to deviations from the towards goal.
reflex poor sucking reflex verbalize usual weight and norm and to
AEB inability to understanding of norms for age, establish baseline
 Inability to breastfeed. causative factors. gender, and body parameters.
breastfeed size. Measure
Long Term Goal: muscle mass or
During NICU calculate body fat.
confinement, the
patient will demonstrate Collaborative:
progressive weight gain  Collaborate with  To set nutritional
toward goal. other health care goals.
members.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

OBJECTIVE: Impaired skin integrity Short Term Goal: Independent:  The patient
related to skin irritation In 3 hours, the patient’s  Inspect skin every  These measures experienced no skin
 (+) Rashes AEB rashes on the left mother will identify shift. Describe and provide evidence of breakdown and
lower quadrant of the causative factors. document skin the effectiveness of maintained
abdomen. condition, and the skin care adequate skin
Long Term Goal: report changes. regimen. circulation.
In 5 days, the patient
will display timely Dependent:
healing of skin rashes  Apply ointment as  Treatment of:
without complications. prescribed. Impetigo,
Secondarily infected
traumatic skin
lesions (up to 10 cm
in length or 100
cm2 area) caused
by Staphylococcus
aureus and
Streptococcus
pyogenes.

Collaborative:
 Along with other  Minimize
health care manipulation of
members, bathe infant’s skin.
infant using sterile
water and mild
soap. Wash only
grossly soiled body
parts.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

OBJECTIVE: Impaired attachment Short Term Goal: Independent:  Identify and prioritize
related to premature In 2 hours, the patient's  Interview parents,  Identifies problem family strengths and
 Baby was born 32 infant AEB infant was mother will identify and noting their areas and strengths needs.
weks AOG born 32 weeks and prioritize family perception of to formulate
 Identify and use
currently in NICU. strengths and needs. situation and appropriate plans.
individual concerns. resources to meet
 Premature baby in needs of family
NICU Long Term Goal:  Assist parents in  Promotes a positive members.
In 5 days, the patient's identifying and attitude by looking at
mother patient's mother prioritizing family what they already do
will demonstrate strengths and needs. well and using those
techniques to enhance skills to address
behavioral organization needs.
of the infant.
Collaborative:
 Collaborate with  Helps promote
other health care healthy
providers in NICU to psychological and
ensure physical
mother/neonate development
contact during visits.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

OBJECTIVE: Risk for aspiration Short Term Goal: Independent:  Caretakers identified
related to enteral In 2 hours, the  Auscultate lung  To determine risk factors.
 Neonatal is on OGT feeding AEB OGT. caretakers will identify sounds periodically decreased breath
risk factors. and observe chest sounds, rales, or
 Patient experiences
radiographs. dullness to
Long Term Goal: percussion that could no aspiratios.
During NICU indicate the
confinement, the presence of
patient will experience aspirated secretions,
no aspiration as and “silent
evidenced by noiseless aspiration” leading to
respirations; clear aspiration
breath sounds; and pneumonia.
clear, odorless
secretions. Collaborative:
 Collaborate with  Supine positioning
other health care and enteral
providers in NICU to feedings have been
avoid keeping the shown to be
client supine/flat independent risk
when on mechanical factors for the
ventilation development of
aspiration
pneumonia.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

OBJECTIVE: Risk for hypothermia Short Term Goal: Independent:  Patient continues to
related to extreme of In 3 hours, the patient  Maintain a warm  Prevention of display core
 Premature neonatal age and delay in will continue to display ambient hypothermia temperature within
(32 weeks) breastfeeding AEB core temperature within environment,
normal range.
 Lack of sucking premature neonatal normal range. especially in facility
and lack of sucking settings.
reflex  Maintains a safe
reflex. Long Term Goal:
In 3 days, the patient’s  Add extra clothing  Prevention of environment.
caretaker will and bedding hypothermia.
demonstrate behaviors promptly.
to monitor and promote
normothermia. Collaborative:
 Collaborate with  Ensure the
other health care prevention of
providers in NICU to hypothermia.
wrap the neonatal in
layers, ensure head
is well covered.