Assessment Diagnosis Planning Implementing Evaluation

Subjective Data: Hyperthermia related  Patient’s  Advised S.O to  The S.O shows
to Neonatal sepsis as temperature will remove extra understanding of
 S.O verbalizes “Kahapon pa evidenced by elevated maintain at clothing to help the health
po siya gin para hirantan temperature normal values regulate teaching that
ngan sige la balik balik.”  Patient’s temperature of was relayed
temperature will the patient  The S.O is now
Objective Data: decreased by  Encourage S.O to capable of caring
the end of the perform for the patient
 Vital signs were taken as shift moderate tepid and can perform
followed:  Patient will sponging to the health
T: 37.2 condition will decrease body teaching that
HR: 128 slowly recover temperature was taught
RR: 60  S.O will show  Instruct the S.O to during the
02SAT: 98 proper breastfeed at assessment.
responsibility of regularly to
 No presence of productive the care of the prevent
cough patient dehydration
 Instruct the
 No presence of ear patient to
secretions breastfeed the
patient in an
 No nose secretions upright position to
prevent aspiration
 Breathing sound is Stridor

 Pink mucosa
 Assessment Diagnosis Planning Implementing Evaluation
Subjective Data: Readiness for  S.O will be able  Encourage S.O to  S.O shows
improving proper cord to practice clean the understanding of
 S.O verbalizes “Didi po sa care as shown and proper cord care surrounding area the advises and
pusod dapit mala nahubag verbalized the need to  S.O will learn of the umbilical teachings that
po.” know that will enhance proper infection stump thoroughly were said
caring of the condition control  Advised to change
Objective Data: of the patient  S.O will be able the diapers of the
to prevent any patient daily
 Vital signs were taken as further  Instruct the S.O to
followed: infections that properly fold the
T: 37.2 could harm the waistband of the
HR: 128 patient diaper for proper
RR: 60 circulation and
02SAT: 98 proper healing

 Redness around the

umbilical stump

 The surrounding area of

the umbilical stump is
tender
 Assessment Diagnosis Planning Implementing Evaluation
Subjective Data: Knowledge deficit  Educate the S.O  Teach the S.O the  The S.O shows
regarding proper about proper proper understanding of
 S.O verbalizes “Deri ko po newborn care and neonatal handwashing the teachings
masyado na gin gagalaw an management related to hygiene technique and that were shown
bata an akon la nahihimo absence of information practices such as importance of and knowledge
pag pasusu la ngan handwashing, hand hygiene imparted
pakaturog tas liwan man bathing, diaper before and after
saiya bado.” changing, cord handling the  The S.O shows
care, skin care, patient. readiness for
Objective Data: nail care, enhanced
clothing,  Instruct to S.O for neonatal care
 Vital signs were taken as bedding hygiene correct technique and
followed: and of diaper changing management
T: 37.2 environmental
HR: 128 cleanliness.  Demonstrate to  The S.O will be
RR: 60 the S.O how to able identify the
02SAT: 98  Demonstrate to trim the patient’s condition of the
the S.O the nails safely patient and has
 The nails of the patient correct now the
appear to be overgrown procedure for  Provide guidance knowledge how
and there is presence of each to the S.O of to manage the
dirt underneath appropriate implementing skin patient’s needs
 overall neonatal care such as
 There is presence of hygiene moisturizers
flushed skin suitable for the
patient
 The patient’s beddings is
crumpled and unorganized  Demonstrate to
the S.O how to
 The patient’s clothing has give a sponge
not been changed yet bath and what
products to use
 The patient has not been that are suitable
bathed for the patient

 Advise S.O for

proper clothing
and bedding