Franz Kenneth Rigor BSN 3-2 (Group 4)

Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective Data: -Deficient fluid Short Term Goal; Independent: Independent: Short Term Goal;
“ang dalas umihi at volume related After 3 hour of - Monitor the patient’s - Monitoring fluid Goal met. After 3 hour
dumumi ni baby, to diarrhea as nursing intervention input and output intake and output helps of nursing intervention
tapos lusaw pa yung evidenced by the baby will: closely assess hydration status the patient decreased in
stool niya sinisinat frequent bowel - decrease in body body temperature
pa siya” as stated by movement temperature - Assess vital signs - Frequent vital sign
patient`s mother. frequently, including checks assist track the Goal met. After 5
After 5 hours of temperature, heart progress of fever and its hours of nursing
Method used: nursing intervention: rate, and respiratory intervention the baby
effect on the body's
Interview rate. had a normal bowel
- The baby will have a overall well-being. It movement.
Objective Data: normal bowel - Encourage mother to allows early diagnosis
Method used: movement. breastfeeding or of complications. Goal met. After 8
Inspection formula feeding as hours of nursing
6 months old After 8 hours of often as usual provide -Encourage regular intervention the baby
Poor skin turgor nursing intervention: additional hydration breastfeeding to avoid had improved
Frequent bowel and nutrition. dehydration and ensure hydration status, as
movement - The baby will have appropriate evidenced by stable
improved hydration - Do continuous tepid nourishment. vital signs, moist
V/S: status, evidenced by sponge bath to the mucous membranes,
TEMP- 38.1 C baby to reduce body - Tepid sponge bath and normal skin turgor.
stable vital signs,
PULSE- 125 BPM. temperature reduces the baby’s
RR- 40 BPM. moist mucous Long Term Goal:
body temperature
membranes, and Dependent:
normal skin turgor. Administer antipyretic Dependent: Goal met. After 2 days
medication as - Lowering of nursing intervention
prescribed to reduce temperature may the baby showed
Long Term Goal: fever and discomfort. sustained hydration and
alleviate discomfort,
a decreased in the
After 2 days of encourage rest, and frequency and severity
nursing intervention: lower the risk of of diarrhea and fever
Franz Kenneth Rigor BSN 3-2 (Group 4)

Collaborative: complications. episodes.

- Collaborate with
- The baby will show other healthcare Collaborative:
sustained hydration providers to closely - Collaboration with
and a decrease in the monitor the baby's other medical
frequency and severity status as you assess professionals ensures
of diarrhea and fever the effectiveness of comprehensive care,
episodes. interventions. supports timely
interventions, and
- Educate caregivers allows for immediate
on fever management adjustments to the care
techniques, such as plan based on the
appropriate clothing baby's response to
and regular interventions.
breastfeeding.
- Teaching caregivers
on fever management
techniques like
appropriate clothes to
reduce overheating and
regular breastfeeding to
maintain hydration.
Franz Kenneth Rigor BSN 3-2 (Group 4)

Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective data: Jaundice related SHORT TERM: INDEPENDENT: INDEPENDENT: SHORT TERM:
“ilang linggo ko na to elevated After 8 hours of - Provide phototherapy - Phototherapy is a safe,
rin napapansin na bilirubin level as nursing intervention, to the infant using effective method for Goal met. The infant’s
medyo naninilaw evidenced by the infant will: fluorescent lights decreasing or bilirubin level
ang balat ng anak yellow (UVA lights) to treat preventing the rise of decreased after eight
ko. Ang sabi ng pigmentation of - show a decrease in physiologic jaundice. serum unconjugated hours of nursing
doctor, hindi raw the skin and serum levels of bilirubin levels and intervention
kasi masyado sclera. bilirubin. - Regulate the reduces the need for
napapaarawan kaya - have improved signs environmental exchange transfusion in Goal met. The infant
naninilaw ang balat of jaundice by temperature/room neonates. have improved signs
ng anak ko.”, as providing temperature of the and symptoms of
verbalized by the phototherapy for at infant. - By keeping babies at jaundice under the
mother of the infant. least 16 hours per day. optimal temperatures, treatment of
- Monitor and record neither too hot or too phototherapy.
LONG TERM: the vital signs of the cold, they can conserve
Objective data: After one week of infant every four energy and build up LONG TERM:
*1 month old baby nursing intervention, hours. reserves. This is Goal met. The bilirubin
*Male term baby the newborn will: especially important levels of the infant was
via NSD - Have his bilirubin - Monitor intake and when babies are sick or within the normal
*Weight: 5kg levels with normal output every shift. premature. range after a week of
*Jaundice range of 0.1 to 1.2 nursing intervention.
mg/dL. - Encourage mother - Includes important
Vitals taken for breastfeeding as data for assessing a Goal met. The infant
T: 36.8 C - have an improved frequent as usual.. child’s health and showed an
P: 118 bpm signs and symptoms development. improvement in overall
R: 38 bpm of jaundice DEPENDENT: skin color with use of
- Administer D5LRS - Monitoring fluid phototherapy.
Methods: Physical IV 400mL to run for intake and output helps
examination and 24 hours as per assess hydration status
observation. physician’s order.
Franz Kenneth Rigor BSN 3-2 (Group 4)

COLLABORATIVE: - More frequent

- Secure umbilical breastfeeding can
cord blood (UBC) and improve the mother’s
Actual platelet count milk supply and, in
(APC) from the turn, improve caloric
laboratory or medical intake and hydration of
technologist. the infant, thus
reducing the elevated
bilirubin.

DEPENDENT:
- Lactated Ringer’s
Solution (also known as
Ringer’s Lactate or
Hartmann solution) is a
crystalloid isotonic IV
fluid designed to be the
near-physiological
solution of balanced
electrolytes

INTERDEPENDENT:
- Cord blood testing is
done to measure the
following in your
baby's blood: Bilirubin
level. Blood culture (if
an infection is
suspected) Blood gases
(including oxygen,
carbon dioxide, and pH
levels)
Franz Kenneth Rigor BSN 3-2 (Group 4)

- Platelet counts are

also ordered to:
Diagnose a platelet
disorder.

.
Franz Kenneth Rigor BSN 3-2 (Group 4)

Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective Data: Ineffective Short Term Goal; Independent: Independent: Short Term Goal;
“dalawang araw na airway clearance After 6 hours of - Increased fluid - Encouraging
po inuubo ‘yung related to nursing intervention intake increased fluid intake Goal met. After 6
anak ko tapos pag retained the patient will: helps maintain hours of nursing
umuubo siya may secretions as - monitor respiration hydration, supports intervention the patient
plema, kagabi hindi evidenced by - have an improve rate and oxygen organ function, and had improved airway
daw siya makahinga productive airway and decrease saturation promotes overall and decreased
ng maayos” as stated cough. difficulty of breathing. health. difficulty of breathing.
by patient`s mother. - teach deep breathing
Have an increase and coughing - Monitoring Goal met. The patient
Objective Data: oxygenation techniques respiration rate and had an increased
5 years old saturation within oxygen saturation is oxygenation saturation
*nasal flaring normal range. -position client in semi crucial for assessing within normal range.
*wheezing sounds fowler’s position or respiratory function. It
when auscultated After 9 hours of elevate the head. helps detect any Goal met. After 9
*productive cough nursing intervention abnormalities or signs hours of nursing
the patient will: Dependent: of respiratory distress. intervention the patient
V/S: - Administer had an increased of
TEMP- 37.1 C - have an increase of salbutamol thru - Deep breathing and respiratory rate within
PULSE- 115 BPM. respiratory rate within inhalation as per the coughing techniques normal range.
RR- 17 BPM. normal range. physician’s order improve lung function,
02sat: 95% prevent atelectasis - had decreased in
- have decrease in (collapsed lung tissue), secretions as evidenced
Method used: secretions as Collaborative: and enhance oxygen by improve breathing
Interview,Inspection, evidenced by improve Secure chest x-ray as exchange. sounds upon
Auscultation. breathing sounds upon per the physician’s auscultation.
auscultation. order. - Positioning the client
in semi-Fowler’s Long Term Goal:
position (head elevated
Long Term Goal: at a 30-45 degree Goal met. After 2 days
angle) helps improve of nursing intervention
Franz Kenneth Rigor BSN 3-2 (Group 4)

After 2 days of lung expansion, The patient

nursing intervention reduces strain on maintained clear
The patient will respiratory muscles, airways as evidenced
maintain clear airways and facilitates by the absence of
as evidenced by the breathing. audible secretions and
absence of audible respiratory distress.
secretions and Dependent:
respiratory distress. - to improve airflow - The patient's
and facilitate cough respiratory function
- The patient's effectiveness. had been maintained
respiratory function
effectively, and had a
will be maintained Collaborative:
effectively, and a - It helps detect lower chance of
lower chance of abnormalities, such as respiratory problems
respiratory problems broken ribs, lung such as pneumonia.
such as pneumonia. tumors, pneumonia,
and pneumothorax (air
collection between the
lungs and chest wall)