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Cues Nursing Objective Intervention Rationale Evaluation

Diagnosis
Subjective: Imbalanced General: Independent: Evaluation date:
“Maeopsi ag nutrition: less than - To facilitate the June 17, 2009
gapanghina ang body requirements maintenance of ♦ Keep strict ♦ This
baby ko” related to inability to nutrition of all information
ingest food because
documentatio Goals: Partially met
(“My baby is pale- body cells n of intake is
of presence of cleft as evidenced by:
looking and weak.” palate as evidenced (count # of necessary
As verbalized by by low Hgb and Hct After 1 week of milk bottles to make an
the mother effective nursing accurate Slight increase in
and inadequate consumed
interventions the nutritional both hemoglobin
formation of RBC. and IVF used)
Objective: patient will be and output assessmen and hematocrit after
• Irritability able to: (count/weigh t. blood transfusion
• Pale conjunctiva Short term: diapers)
and pallor  Gain 2 lbs per Lab test results
• Weakness 06/16/2009:
week
Hgb – 10.9 gm/dL
Long term:  Explain the
Lab test results  The Hct – 36%
 Exhibit no importance of RBC – 4.67 M/µL
06/15/2009: mother/care
signs or adequate
Hgb – 6.8 gm/dL giver may
symptoms of nutrition and
Hct – 23% have
RBC – 2.91 M/µL malnutrition by fluid intake to
inadequate
time of the
or
Normal values: discharge from mother/caregi
inaccurate
Hgb (newborn) : 15-25 gm/dL
treatment ver
Hct (child): 30 – 42% knowledge
RBC: 3.5 – 5.0 M/ µL (e.g., regarding
electrolytes the proper
and blood of feeding
counts will be of a baby
within normal with the
limits; a steady said
weight gain disability
will be
demonstrated;
patient will  This will
exhibit facilitate
increased  Instruct the
energy). mother/caregiver to sucking and
feed the infant will make
gently using a feeding
commercial cleft easier for
lip nipple
the baby

 Instruct the
mother/caregi
ver that when
feeding the
infant,, place  This position
the infant in a will improve
90-degree swallowing
position with ability of the
the head infant
slightly
flexed.

Collaborative:  Laboratory
 Monitor values
laboratory provide
values, and objective
report data
significant regarding
changes to nutritional
physician. status
♦ Administer meds
as indicated:  This drug
- Ferlin i ml BID therapy will help
-Folic Acid 5 mg i in the adequate
tab OD formation of
-Fortum 270 mg IV RBCs
q2H NST

 Administer blood
transfusion as  This will treat
prescribed the increase level
of both
hemoglobin and
hematocrit