ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Subjective: Ineffective Airway After 5 minutes of  Wipe off the  To clear the After 5 minutes
Clearance nursing patient’s face opening of the of nursing
Objective intervention the mouth and airways. intervention the
patient’s airway nose patient’s airway
- Bluish will be free from is free from
discoloration mucus secretions mucus secretions
- Muscle and will maintain  Suction first  To clear and maintained
flaccid breathing the mouth excess fluid breathing
- Mucus then the that cause
secretions nose. difficulty of
breathing
Vital Signs
HR – 0
RR – 0  Place the
patient head  To open
midline with airways and
extension help maintain
airway
 ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective Ineffective After 1 hour of  Monitor vital  To establish After 1 hour of

thermoregulation nursing signs baseline nursing
Objective related to interventions the intervention the
premature delivery. patient will be patient is able to
- Bluish able to improve  Perform  Provides heat maintain normal
discoloration his temperature swaddling and warm body temperature
- Rapid from 35.4 c to technique
respirations 36.5 c

Vital Signs  Maintain  To maintain

warm and
stable
HR - 148 ambient
RR - 55 temperature
environment
T – 35.6 and prevent
loss of heat
through
conduction,
convection,
radiation and
evaporation.

 Place the  To prevent

baby in heat loss
radiant
warmer
 ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective Risk for Infection Within  Observe  To reduce or Within the

related to confinement, the hygienic prevent confinement the
prematurity patient will be free technique to transfer of patient is free
Objective from any signs of everyone that microorganism from any signs of
infections as will be in infections as
- Diminished manifested by contact with manifested by:
spontaneous the patient
activity  Stable vital  Stable
- Poor signs vital signs
sucking  Ensure that  To reduce or
reflex all equipment prevent
that will be transfer of
used by the microorganism
Vital Signs patient is
HR = 130 bpm sterile
RR 30 bpm
T = 37C
 Place the  Allows close
infant in the observation
isolation and protect
room from other
infants

 Give proper  To have a good

food intake nutrition
  Monitor lab  Provide
results as information
obtained about increase
of WBC.

Independent
 To
 Administer
inhibit/fight
antibiotics as
the growth of
ordered by
the doctor infection
 ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective Risk for After 1 week of  Document  To establish After 1 week of

Imbalanced nursing actual weight baseline for nursing
Nutrition: Less intervention the future intervention the
Objective than Body patient will be able evaluation patient have good
Requirements to develop sucking sucking reflex.
- No sucking reflex.  Monitor food  To see if there
reflex intake of the will be
- 1.71kg birth patient changes in
weight through OGT
feeding
- Lethargic
pattern of the
patient

 Teach the  To provide

mother on milk for the
breast baby
pumping

 Encourage  To prevent
the mother to colic pain
burp the baby
every after
feeding.

 To stimulates
 Give ample
the baby’s
amount of
milk through sucking reflex
the mouth