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Nursing Care Plans

ASSESSMENT NURSING

DIAGNOSIS

PLANNING NURSING

INTERVENTIONS

RATIONALE EVALUATION

Subjective:

n/a

Objective:

- Preterm birth (34weeks)

- Irregularbreathing

pattern

Ineffective

breathing

pattern related

to immature

neurologic and

delayed

pulmonary

development

After 1 hour of

nursing

interventions, the

infant will have an

improvement in his

breathing pattern.

INDEPENDENT:

(1) Monitor vital

signs

(2) provide

respiratory

assistance as needed

(oxygen hood)

(3) position infant on

side with a rolled

blanket behind his

back

(4) provide tactile

stimulation during

periods of apnea

(1)Provide a

base line data

(2) assistance

helps the

newborn by

clearing the

airway andpromoting

oxygenation

(3) lying on the

side position

facilitate

breathing

(4) stimulation

of the

sympatheticnervous system

increases

respiration

After I hour of

nursing

interventions, the

infants breathing

pattern improved.

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ASSESSMENTNURSING

DIAGNOSISPLANNING

NURSING

INTERVENTIONRATIONALE EVALUATION

Subjective:

N/A

Objective:

Birth weight:1.1 kgs

Poor muscletone

Small forgestational age

Imbalanced

nutrition: less

than body

requirements

related to

biological

factors

After 1 day of nursing

intervention, the infant

will receive adequate

fluid and nutrients for

growth.

INDEPENDENT:

(1)Assess the infants

weight

(2)Make sure the

neonates tongue is

properly positioned

under the nipple of the

mother

(3)Monitor the neonate

for signs of

dehydration, such as

poor skin turgor, dry

mucous membranes,

increase or

concentrated urine, &

sunken fontanels and

eyeballs.

(4)Promote adequate

or timely fluid intake.

(1)To establish a

baseline data

(2)To enable the

neonate to suck

adequately

(3)To establish the

need for

immediate medical

intervention

(4)To reduce

possibility of early

satiety

After 1 day of

nursing

intervention, the

infant received

adequate fluid and

nutrients for

growth.

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ASSESSMENT NURSING

DIAGNOSIS

PLANNING NURSING

INTERVENTIONS

RATIONALE EVALUATION

Subjective:

-n/a since a potential

diagnosis

Objective:

- Prolongedstay in the

hospital

- Prematureage (34weeks)

-- HR: 148 bpm- Labs:Increased WBC

levels

Risk for

infection r/t

spread of

pathogens

secondary to

identified

sepsis and

immature

immune

system

After 8 hours of

nursing

interventions the

infant will not

experience spread

of infection.

INDEPENDENT:

(1) ensure that all

people coming in

contact with infant

wash their hands

well before & after

touching the baby

(2) Ensure that all

equipment used for

infant is sterile,

scrupulously clean &

disposable. Do not

share equipmentwith other infants

(3) place infant in

isolation room per

hospital policy

(4) assess TPR & BP,

auscultate breath

sounds

(1) hand washing

prevents the spread

of pathogens coming

from the infant to

the caregiver and

vice versa

(2) this would

prevent the spread of

pathogens to the

infant from

equipment

(3) Allows close

observation of the ill

neonate & protects

other infants from

infection

(4) assessments

provide information

about the spread ofinfection, increased

RR and HR,

decreased BP are

signs of sepsis.

Spread of infection

may cause resp.

distress

After 8 hours of

nursing

interventions, the

infant did not

experienced spread

of infection

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(8) monitor lab

results as obtained.

Notify care giver of

abnormal findings

DEPENDENT:

(10) administer IV

fluids as ordered

(D10IMB)

(11) administer

antibiotics as

ordered

(8) lab results

provide information

about the pathogen

and infants response

to illness and

treatment

(10) IV fluids help

maintain fluid

balance

(11) Antibiotics act

to inhibit the growth

of bacteria and

destruction of

bacteria.