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Objectives: Risk for Increased risk within the monitor to serve > goal
weak in infection r/t for being shift, the vital baseline partially met
appearance inadequate invaded by patient’s signs data Athe patient is
(+)sclerema acquired pathogenic health provide to still in
immunity. organism that condition comfort maximize observation
yellowish
can lead will measures comfort
in color
infection partially by fixing
with
improved bed linen
ongoing
orogastric keep the to keep
tube intact baby warm the baby
vital signs and dry warm and
taken as to prevent
follows from
chilling
CR–140bpm
promote to prevent
RR–46bpm
thorough cross
Temp. handwashin contaminat
36,4ºc g by ion of
caregiver bacteria
Assessment Nursing diagnosis Scientific background Nursing goal Nursing intervention Rationale evaluation
Objectives: Ineffective airway Inability to clear At the end of the shift Vital signs To serve Goal partially met. The
weak cry clearance r/t secretions secretions from \the the patient will monitored and baseline data patient is still with
yellowish in in the bronchi respiratory tract to partially improve recorded moderate coffee grown
color maintain a clear airway Administer To promote secretions flowing from
with oxygen oxygen proper lung the orogastric tube.
inhalation at 1- expansion
2/min. Provide comfort To maximize
with orogastric measures by comfort
tube intact fixing bedlinen
flowing to a Use sterile wet To prevent
coffee grown cotton to wipe drying of the
secretions with the lips. lips
moderate
amount
dry lips noted
v/s taken as
follows :
RR-30-bpm
CR-150bpm
Temp-36ºc
Assessment Nursing Diagnosis Sientific background Nursing goal Nursing intervention Rationale Evaluation
Objectives: Hypotermia r/t After 1-2hours of monitor v/s to serve Goal met, at the end of
yellowish in inadequate clothing proper nursing baseline data the shift the patient
color intervention the body provide to maximize body temperature will
facial grimace temperature will comfort comfort increased to normal
weak in increase to normal measure by level
appearance level fixing bedlinen
v/s taken as to keep the
follows: RR- keep the baby baby warm and
40bpm warm and dry to prevent from
CR-140bpm chilling
Temp.34.9ºc
promote to prevent
thorough contamination
handwashing of bacteria
by caregiver