ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: (Potential) Goal: After nursing ● Teach proper Goal met. After weeks
interventions, the breastfeeding of nursing intervention,
Mother states that the Risk for imbalanced newborn will manifest techniques to the newborn is able to
baby shows little to no nutrition, less than body signs of a mother. manifest signs of a
energy sucking which requirements related to well-nourished newborn well-nourished newborn
makes it difficult to lack of energy for and will show the ability Rationale: To increase and has shown the
breastfeed her baby. sucking to suck properly. her knowledge and to ability to suck properly.
prevent further struggle
Objective: Objectives: After of newborn while Objective met. After
nursing interventions, breastfeeding. days of nursing
Mother shows lack of the mother will be able interventions, the
knowledge about to: mother is able to show
breastfeeding ● Assess signs of proper
techniques which leads - Show signs of newborn's knowledge about
to her baby's difficulty proper weight regularly, breastfeeding
when sucking. knowledge and assess for techniques.
about possible
breastfeeding dehydration.
techniques.
Rationale: To keep
track of the newborn's
overall health status
and to prevent
malnutrition.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Newborn has dyspnea. (Actual) Goal: Assess newborn's RR, Goal met. After nursing
BP, and temperature interventions, the
Newborn has abnormal Ineffective airway The newborn will show regularly newborn is able to show
RR. clearance related to the signs of effective and signs of effective and
presence of mucus or clear airways as Rationale: To keep clear airways as
amniotic fluid in the evidenced by normal track of the newborn's evidenced by normal
airway breath sounds and overall health status. breathing sounds and
normal vital signs. Increased work of normal vital signs.
breathing can lead to
hypertension.
Continuous secretions
can lead to infections.

Regularly keep track of

newborn's oxygen
saturation using pulse
oximeter.

Rationale: Oxy sat

should be maintained
over 94%. Any lower
than that is dangerous.

Position newborn on a
supine position with the
head to the side or in a
neutral position.

Rationale: To promote
discharge of mucus in
the airways

Use bulb syringe as

necessary to suction
secretions when there
is discharge in the nose
or mouth.

Rationale: To clear the

airways of the newborn
by removing the
secretions in the nose
and mouth.