CONCEPT MAP

NDx # 3 Risk for

infection r/t
maturational factors
Four day old infant
and immature immune
baby with a body
system
temperature of 38.1 C Objective Cues:
- Patient is 4 day
Priority Assessment:
old infant
Vital Signs
P.E.
Family History
Age
Motor movement
NDx # 2 Ineffective
NDx # 4 Risk for
breastfeeding r/t
imbalanced body
unsatisfactory feeding
temperature r/t
process.
Patients Initials: S.M
Medical Diagnosis/Chief Complaint: Infant had aineffective
fever
Subjective and
Cues:could not breathe properly
thermoregulation
- Palaging umiiyak at
NDx # 5. Readiness for secondary to extremes
Age: 4 Gender: gutomBasis
for
Prioritization:
Maslows
Needs
ang anak ko.
of age (newborn status)
enhancedHierarchy
organizedofinfant
As verbalized by
days
Female
behavior r/t increasing Subjective Cues:
mother.
stability of autonomic, - Nalagnat ang anak ko
Category: Single
Date Admitted: August 10,
Prepared by: Kristoffer
Objective Cues:
huling umaga pero
motor, and state responses
2015is not
Villa
- The infant
to environmental cues nawala siya sa hapon. As
verbalized by the mother.
Objective Cues:
responsive
Objective Cues:
Infant is adapting
- Fussy and crying to
- Babys axilla temp:
well to the
mothers comfort
environment. 38.1C; skin warm and dry
measures.

Is showing proper
- Inability to latch on
motor movements
to nipple correctly

NDx # 1 Ineffective
Airway clearance r/t the
excessive fluid and
mucus in the newborns
respiratory passages
Objective Cues:
- Productive cough
- Runny nose
- Restlessness

NDx # 1 Ineffective Airway clearance r/t the excessive fluid and mucus in the
newborns respiratory passages
Goal: The infant will maintain airway having a respiratory rate within normal range
Expected Outcomes: At the end of the duty, the client will be able to:
a. Shows no evidence of adventitious breath sounds
b. Maintains a patent airway at all times
c. Maintain a respiratory rate within normal limits.
Interventions
Independent
1. Look for signs of
respiratory distress,
including tachypnea,
retractions, flaring of the
nares, pallor or cyanosis,
grunting, seesaw
respirations, and
asymmetry of chest
movements.

Rationale

Outcome Indicators
-

The infant will be

able to breathe
properly without any
signs of distress.

The infant will not

show any abnormal
breath sounds when
auscultated.

The infant will

maintain a
respiratory rate
within normal range.

The infant will

receive the
medications or
management if

1. This will aid in detecting

an abnormalities that need
further interventions.

2. Note the rate and

character of the heart rate,
pulses, respirations, and
breath sounds.

2. Early detection could be

seen through these vital
signs.

3. Do health teaching and

point out characteristics of
the infants possible
respiratory status changes
to the mother.

3. Early recognition of the

onset of respiratory
difficulties could mean
saving that infants life.

4. Position infant
appropriately.

4. To mobilize secretions.

5. Observe for
5. To identify infectious
signs/symptoms of infection process/promote timely
(e.g., increased dyspnea,
intervention.
onset of fever, increase in
sputum volume, change in
color or character)
Dependent
1. Check Doctors orders
for medications, O2
therapy, or any other
management.

To aid in providing an
effective air way clearance.

Collaborative
1. Refer if there are any
complications.

needed.
Prompt and attention
treatment will produce a
better prognosis and
speedy recovery.

The patient will not

show any signs of
complications or
respiratory distress.

NDx # 2 Ineffective breastfeeding r/t unsatisfactory feeding process.

Goal: The infant will be able to effectively breastfeed.
Expected Outcomes: At the end of the duty, the client will be able to:
a. The mother will express physical and psychological comfort in breastfeeding practice
and techniques.
b. The infant will feed successfully on both breasts and appear satisfied for at least 2
hours after feeding.
c. The infant will grow and thrive.
Interventions
Independent
1. Conduct health teaching
about proper
breastfeeding, breast care
and care for the infant

Rationale

1. Help the client

understand the proper
facilitation of care of the
infant and to provide
satisfying feeding time for
both mother and baby

2. Inform the mother about

the early infant feeding (e.g
rooting, lip smacking and
sucking fingers/hands)

2. Promotes timely feeding

experience for infant and
mother

3. Encourage the mother to

stroke the neonates cheek
with fingers or the nipple

3. Encourage let-down
reflex

4. Assess breast and nipple

structure

Dependent
1. Check Doctors orders

Normal nipple and breast

structure or early detection
and treatment of
abnormalities with
continuing support are
important for successful
breastfeeding
To oversee that the
prescribed management is
done.

Outcome Indicators
-

The mother will be

able to breastfeed
her baby effectively

The baby will be able

to stop crying and
show satisfactory
response to
breastfeeding
process.

The mother will

effectively breastfeed
with no problems

The mother will not

complain of troubled
breastfeeding from
sore or painful
areolas.

Collaborative
1. Refer to a Dermatologist
1. To check the dry cracked
areolas of the mother.

NDx # 3 Risk for infection r/t maturational factors and immature immune system
Goal: The infant will remain free from infection.
Expected Outcomes: At the end of the duty, the client will be able to:
a. Maintain normothermia
b. Mother of child will verbalize measures to decrease infection in her newborn
Interventions
Independent
1. Monitor vital signs every
4 hours.

Rationale

1. Provides baseline and

allows for quick
identifications of any
deviations that could
indicate infection

2. Institute aseptic
precautions, especially
handwashing, around
infant.

2. Protects baby from

pathogens.

3. Teach the clients mother

about infectious process,
including routes,
pathogens, environment
and host factors as well as
proper hygiene.

3. Provides basic
knowledge for protecting
newborn

4. Assess skin for color,

moisture, texture, and
turgor (elasticity). Keep
accurate, ongoing
documentation of changes.

4. Preventive skin
assessment protocol,
including documentation,
assists in the prevention of
skin breakdown. Intact skin
is nature's first line of
defense against
microorganisms entering
the body

Outcome Indicators
-

The infants vital

signs will be in
normal range

The infant will remain

free from infection
and will show no
evidence of it

The mother will

verbalize the
importance of proper
handwashing
and hygiene

The pts lab results

will be within normal

Dependent
1. Check for the laboratory 1. To know the immunologic
results and Doctors orders. status and the prescribed
management.
2. Report signs of infection
such as redness, warmth,
discharge, and increased
body temperature.

range and the

mother will see that
her infants
management is
carried out.

2. With the onset of

infection the immune
system is activated and
signs of infection appear.

Collaborative
1. Refer to Medical
Technologist for laboratory
exams.

The patient will have

normal lab exams.

1. To indicate the patients

health status.

NDx # 4 Risk for imbalanced body temperature r/t ineffective thermoregulation

secondary to extremes of age (newborn status)
Goal: The infant will maintain its body temperature within normal range.
Expected Outcomes: At the end of the duty, the clients mother will be able to:
A. Clients mother will maintain body temperature within normal range
b. The mother will verbalize understanding of risk factors and appropriate interventions
c. Mother will verbalize infants behaviors and monitor and maintain the infants body
temperature
Interventions

Rationale

Independent
1. Assess infants temp
each hour.

1. Infants lack mature

thermoregulation. Temps
too high or too low can
disrupt acid-base balance,
causing seizures or shock

2. Assess environmental
temperature and modify, as
needed.

2. Manipulating ambient air

around infant will prevent
imbalanced body
temperature.

3. Perform tepid sponge

bathe.

3. To decrease the infants

temperature.

4. Monitor laboratory
values

4. To identify causative/risk
factors present

5. Instruct the mother

5. To promote wellness

Outcome Indicators
-

The infants
temperature will
remains within
normal limits

The mother will

verbalize and
understanding of the
risk factors and
proper management.

The mother will

identify the infants
behavior and keep
the infants
temperature within
normal range.

measures to protect the

infant by identifying risk
factors
Dependent
1. Check Doctors orders

Collaborative
1. Refer to an
Immunologist

The infants
temperature will be
normal.

The infant will

present a good
immune system.

1. To oversee that the

prescribed management is
done.

1. To improve patients
immunologic function.

NDx # 5 Readiness for enhanced organized infant behavior r/t increasing stability
of autonomic, motor, and state responses to environmental cues.
Goal: The infant will continue to adapt appropriately to environmental stimuli
Expected Outcomes: At the end of the duty, the client will be able to:
a. Infant will exhibit smooth movements such as hand-to-mouth, suck, swallow.
b. Infant exhibits organized behaviors such as maintaining quiet alert states, engages in
reciprocal interaction with parent, self-consoling, etc.
Interventions
Independent
1. Assess mothers
understanding of infants
current behavioral states
and cues

Rationale

Outcome Indicators
-

The infant will be

able to present
smooth movements
such as hand-tomouth, suck, swallow

The infant will be

able to adapt and
respond to
environmental
stimuli.

The mother will be

able to verbalize that
the infant has
developed a
sleep/wake pattern;

1. It provides baseline
information.

2. Assist mothers to
identify when the infants
behavior indicates stress
cause by excess
environmental stimuli such
as noise.

2. It helps the mother

modify stressors.

3. Encourage mother to
decrease stimuli when
infant appears
overstimulated

3. Promotes infant
development without
excessive stress.

4. Observe the parents

interactions with the infant:
eye contact, stroking,
talking to the baby. Point
out attractive features and
infants responses to
parents.

4. Observation helps
identify the appropriate
behaviors related to
attachment and bonding
with the infant.

5. Offer encouragement to
fathers to touch and hold
their infant.

5. It provides the novice

father with permission to
parent.

Dependent
1. Check Doctors orders

Collaboration
1. Refer to Behavior
Therapist

infant responds to
visual and auditory
cues; and infant
demonstrates ability
to console self, etc

The infant will show

normal actions or
reactions to external
or internal stimuli

The infant will

present an
appropriate growth
and development
and behavior.

1. To oversee that the

prescribed management is
done.

1. To promote healthy
development of behavior