Nursing Care Plans NURSING DIAGNOSIS Subjective: Ineffective breathing n/a pattern related to immature Objective: neurologic and

delayed - Preterm birth (34 pulmonary weeks) development Irregular breathing pattern ASSESSMENT PLANNING After 1 hour of nursing interventions, the infant will have an improvement in his breathing pattern. NURSING INTERVENTIONS INDEPENDENT: (1) Monitor vital signs RATIONALE EVALUATION After I hour of nursing interventions, the infants breathing pattern improved.

(1)Provide a base line data

(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

(2) assistance helps the newborn by clearing the airway and promoting oxygenation (3) lying on the side position facilitate breathing (4) stimulation of the sympathetic nervous system increases respiration

ASSESSMENT Subjective: N/A Objective: Birth weight: 1.1 kgs Poor muscle tone

NURSING DIAGNOSIS Imbalanced nutrition: less than body requirements related to biological factors

PLANNING After 1 day of nursing intervention, the infant will receive adequate fluid and nutrients for growth.

NURSING INTERVENTION INDEPENDENT: (1)Assess the infants weight (2)Make sure the neonates tongue is properly positioned under the nipple of the mother

RATIONALE

EVALUATION After 1 day of nursing intervention, the infant received adequate fluid and nutrients for growth.

(1)To establish a baseline data (2)To enable the neonate to suck adequately

Small for gestational age

(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.

(3)To establish the need for immediate medical intervention

(4)To reduce possibility of early satiety

ASSESSMENT Subjective: -n/a since a potential diagnosis Objective: Prolonged stay in the hospital Premature age (34weeks)

NURSING DIAGNOSIS Risk for infection r/t spread of pathogens secondary to identified sepsis and immature immune system

PLANNING After 8 hours of nursing interventions the infant will not experience spread of infection.

NURSING INTERVENTIONS 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 equipment with other infants (3) place infant in isolation room per hospital policy

RATIONALE

EVALUATION After 8 hours of nursing interventions, the infant did not experienced spread of infection

(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

- HR: 148 bpm - Labs: Increased WBC levels

(4) assess TPR & BP, auscultate breath sounds

(3) Allows close observation of the ill neonate & protects other infants from infection (4) assessments provide information about the spread of infection, increased RR and HR, decreased BP are signs of sepsis. Spread of infection may cause resp. distress

(8) monitor lab results as obtained. Notify care giver of abnormal findings

(8) lab results provide information about the pathogen and infants response to illness and treatment

DEPENDENT: (10) administer IV fluids as ordered (D10IMB) (11) administer antibiotics as ordered

(10) IV fluids help maintain fluid balance (11) Antibiotics act to inhibit the growth of bacteria and destruction of bacteria.