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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.
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