ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

STG: INDEPENDENT INDEPENDENT STG:

Subjective: Impaired gas After a series of nursing 1. Establish rapport 1. To gain trust and Goal Met.
 Unusually Exchange interventions, the client will 2. Perform hand hygiene and cooperation of the mother Patient exhibits
underweight Related to be able to demonstrate put on PPE, if indicated. 2. Hand hygiene and PPE improved
(2450g) Immaturity of improved ventilation. 3. Monitor VS and cardiac prevent the spread of ventilation.
 Pretern birth Newborn’s rhythm microorganisms.
lungs LTG: 4. Provide oxygen at lowest 3. Ensures progress of LTG:
Objective: And lack of After 3-4 days of nursing concentration indicated by treatment. Goal Met.
Surfactant as interventions, laboratory results and 4. Stabilizes oxygenation. The mother was
 Mild respiratory evidence by  The mother will be client symptoms/situation. 5. Helps limit oxygen needs able to define what
distress, minimal mild able to define what 5. Promote a calm and restful and consumption. RDS mean and
subcostal and respiratory RDS means environment. 6. Ensures progress of understand the
intercostal distress accurately and will 6. Auscultate breath sounds, treatment. importance of
retractions be able to discuss. note areas decreased rales 7. To make sure that the RR proper ventilation
 The mother will be or gruntin sounds. is normal and no signs of on her child.
able to understand 7. Note respiratory rate and pallor or cyanosis.
the importance of assess areas of pallor or The client shows
proper ventilation on cyanosis. DEPENDENT: absence of
her child precisely. 1. Infants with respiratory symptoms of RDS.
 The client will be DEPENDENT: distress will receive
able to show standard of care fluid
absence of 1. Administer D10Water management to mimic
symptoms of RDS. 209.5 ml + Na CL 3ml + K CL fluid intake of normal
2.5 ml + 10% Ca Gluconate healthy breast fed infant.
5 ml to run for 9.2 ml hour 2. Ampicillin sodium &
via infusion pump as sulbactam sodium is a
ordered combination antibiotic
2. Administer Ampicillin- indicated for the neonatal
Sulbactam 250 mg IV every intensive care unit (NICU),
12 hours as ordered used for treatment of
3. Administer nutrition via bacterial infections
enteral feedings including sepsis and
meningitiss
3. To help getting the
nutrition they need to
grow and develop.
JOSE, LEANA LOUISSE D.
Ardel was born to a 27 year-old G5P4 mother via CS with BW of 2, 450 grams. Mother had UTI 2

months prior to delivery. Ardel showed a late pre-term looking male newborn in mild respiratory

distress with minimal subcostal and intercostal retractions. Oxygen was given via nasal cannula due

to respiratory distress and was worked up. CBC, RBS, Blood CS, Blood typing and Babygram were

ordered and done. Patient was initially kept on NPO and started with parenteral nutrition

(D10Water 209.5 ml + Na CL 3ml + K CL 2.5 ml + 10% Ca Gluconate 5 ml to run for 9.2 ml hour via

infusion pump). Ardel started on Ampicillin-Sulbactam 250 mg IV every 12 hours.

JOSE, LEANA LOUISSE D.

BSN 2B1

REFLECTIVE JOURNAL

DESCRIBE
Describe your experience objectively.

- On Monday night I did my own individual activity (NCP) which at first I feel lost since It’s been months I
think since the last one I did make one but I managed to analyze the situation with the help of NANDA and my
previous NCP as my guide although I was still instructed to make some revisions but it’s okay since I learned
more on how to properly make one. The next day my group mates and I did a concept map which is also about
the given case scenario and we decided to make our own concept map first then we will combine our work
after. However, we had a hard time to analyze it alone so the night before the due date we all gathered in
google meet to talk about the activity, hand out our parts and how we will combine our work into 1 concept
map, so we did 2 concept map that night to make sure that were doing the right thing, in the end the first one is
what we presented the next day and everything went smoothly with little revisions here and there but all is
good.
EXAMINE
KNOWLEDGE

Did any academic concepts become apparent during this experience? Did you need to change your approach
after new information and experiences were presented to you?

- Yes, actually I learned a lot in this topic and realize how important it is for a student nurse like me to
know and to learn all different types of trauma, injuries and animal bites that I can use in the upcoming years,
also learning the different gowning and gloving techniques. Yet I still have a lot to learn and I believe that I do
need to change my approach specially in making a nursing care plan. Because I realized that nurses uses a
systematic, dynamic, rather than static way to collect and analyze data about a client which is the first step in
delivering nursing care, where you have to look outside the box in analyzing the situation so you can determine
the priority and like know the predisposing and precipitating factors that can affect the patient before making
conclusions or any nursing diagnosis especially if you will look at the case scenario given.
SKILL
What was the goal you were trying to accomplish?

- My goal is to Identify and describe different types of head Trauma, Abdominal Trauma, Animal Bite,
Thermal Injuries, Foreign Body Obstruction and to formulate nursing diagnosis related to the case scenario
given, how to Plan nursing care focused on promotion and prevention of complication to Integrate knowledge
with analytic, communicative and collaborative skills in developing and presenting a case study. I believe that
I’ve achieve my goal as I understand and learned a lot from the topics that have been discussed however I still
have a lot learn especially in administering medicines for example meds used to prevent infection or meds used
to reduce edema and pressure and things like that. It is an easy but also a tough one since you really have to
critical thinking or reflect in the situation given like in the predisposing factors which is the age of the child but
you have to think more from it in a way that can put a child at risk of developing a problem that include
genetics, life events or temperament, so it’s not just the age of the child there’s more to it to consider.

VALUES
How did your strengths and weaknesses contribute to working towards the goal you were trying to accomplish?
What were the positive and negative effects of these personal characteristics?

- I honestly believe that if you accept your weaknesses no one can use that against you and will eventually
diminish your fears and people will value the way that you're willing to show your vulnerability, you’ll reduce
your ego which will allow you to accept constructive criticism without feeling hurt. I’m person with a lot of
shortcomings and I’m also a slow learner which I’m really insecure about because I have to study and
comprehend all the topics 2x harder unlike other kids and a lot of times I have to ask other people like ate zai
and my friends from block a for me to understand more about the topics and I think my hunger for knowledge
and my passion for my course are my strengths that contributes in achieving my goals although I know it is not
enough but I’m trying and thriving for myself.
MOTIVATION
Did this experience have any influence on your future educational or career path?

- Yes, because it motivates me to keep going in achieving my goals even though sometimes I feel like giving
up because we all know that nursing is really a tough course and the all topics are not a joke and struggle is real
but there’s a lot of things that keeps me going especially when we’re doing skills lab because you learn the
actual work that really happens in the field that inspires you to work harder.
ARTICULATE LEARNING (ESSAY)
I learned how to identify and define different types of head and abdominal Trauma, different types of
animal bite and how to compute ATS or the Anti-Tetanus Serum which is used to treat animal bites, I also
learned about thermal Injuries, different degrees of frost bites and burns and also the therapeutic management.
We also learned how to formulate nursing diagnosis related to the case scenario given and how to plan nursing
care focused on promotion and prevention of complication to integrate knowledge with analytic,
communicative and collaborative skills in developing and presenting a case study.
We were able to comprehend all of the topics thru communicating and engaging with the activities and
also in participating in the synchronous class led by Ma’am Aizelle Fredeluces which is our CI of the week and
she thought us a lot of things by explaining, showing us photos and giving us ideas about the topics being
discussed. In my opinion it is very essential to know all of the topics that have been discussed because children
is an important public health goal and their well-being determines the health of the next generation and can
help predict future public health challenges for families, communities, and the healthcare system and also the
skills demonstrated the Perioperative Nursing, Gowning and Gloving is a must to learn because it is a standard
to eliminate some of the controllable sources of contamination and to prevent contamination to the surgical
wound and help control infection is via aseptic principles and standard precautions which help ensure the
control of infection and microbial contamination by skin flora.