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ASSESSMENT NSG

SCIENTIFIC

GOAL/OBJECTIVES NSG.

DIAGNOSIS BASIS Subjective:

Impaired

Neonatal

“Maglisod na

gas

siyag hinga” as

RATIONALE

EVALUATION

INTERVENTION After 8 hours of

>Assess

>Manifestation After 8 hours of

pneumonia is nursing

respiratory rate,

of respiratory

proper nursing

exchange

lung infection

interventions, the

depth and

distress is

intervention, the pt

verbalized by

related to

in a neonate.

patient will achieve a

Heartrate of

dependent on

has achieved a

the mother.

thick

Onset may be

timely resolution of

patient.

indicative of

timely resolution of

mucous

within hours

current infection

the degree of

current infection

Objective:

secretions

of birth and

without complication.

lung

without negative

> Dyspnea

Secondary

part of a

A.) The pt will have a

involvement.

complication as

>Tachycardia

to Neonatal

generalized

normal rate of rr to

>Monitor the

>High fever

eveidenced by:

>Irritability

Pneumonia

sepsis

50 from 64 cpm.

body

greatly

(-) Tachycardia PR-

RR: 64 cpm

syndrome or

B.)The pt will have a

temperature.

increase

130bpm

PR:170 bpm

after 7 days

normal beating from

metabolic

(-)Dyspnea RR-

and confined

170 bpm to 130 bpm.

demand and

50cpm

to the lungs.

C.) The patient will

oxygen

(-)Irritability

Signs may be

have arelief from

consumption.

limited to

irritability as

>Elevate head

> To provide

respiratory

evidence by the

of the Patient.

comfort for the

distress or

infants sleep.

>Encourage

patient.

progress to

mother to do

>To easily

shock and

postural

facilitate

death.

drainage on

secretion from

Diagnosis is

patient.

the patient.

by clinical and

>Assist with

>Facilitates

laboratory

nebulaizer

liquification

evaluation for

treatments care

and removal

sepsis.

of pulmo.

of secretions.

>Have meds given to pt as

>Drugs used

prescribed by

to combat

the AP.

most of the mincrobial pneumonia.

ASSESSMENT

Subjective: “Dili nako kbalo

NSG.

SCIENTIFIC

DIAGNOSIS

BASIS

Risk for

Parenting is

The mother will

>Interview

Impaired

providing a

identify and

parents, noting what the

nurturing and

demonstrate

their

constructive

techniques to

environment

enhance behavioral

disease

that promotes

organization of the

process of

growth and

neonate

development

After discharge the

concerns

in a child or

parents will be able

>Educate

Helps clarify

After discharge

children

to have a mutually

parents

realistic

the parents will

to Neonatal

satisfying

regarding child expectations

be able to have a

Sepsis.

interactions with

growth and

mutually

unsay hmuon nako inig gawas namo drias hospital.”

Objective: >Fearful >Irritable

Parenting related to

newborn Secondary

GOAL/OBJECTIVE NSG.

RATIONALE

EVALUATION

>To know

The mother will

INTERVENION

their newborn.

perception of situational and

parents

demonstrate

feelings about

techniques to

the situation.

enhance behavioral

individual

organization of the neonate

satisfying

development,

interactions with

addressing

their newborn

parental

negative from

perceptions

fearfulness.

>Involve

>Enhances

parents in

self-concept

activities with

identify and

the newborn that they can accomplish successfully >Recognize

>Reinforces

and provide

continuation

positive

of desired

feedback for

behaviors

nurturing and protective parenting behaviors

ASSESSMENT NURSING DIAGNOSIS Subjective:”Init

SCIENTIFIC

GOAL/OBJECTIVES NURSING

BASIS

Hyperthermia Neonatal

RATIONALE EVALUATION

INTERVENTION After 2 hours of

>Provide Tepid

>Enchances

After 2 hours of

Sponge bath.

heat loss by

comprehensive

kayo siya knina related to

sepsis is a

comprehensive

murag on and

infection

type of

Nursing Intervention,

evaporation

intervention the pt

off iyng fever.”

process

neonatal

the patient will lower

and

has been free from

As verbalized

Secondary to

infection and

down its body temp

conduction .

hyperthermia as

by the mother.

Neonatal

specifically

to normal level as

>Assess fluid

>Increases

evidenced by:

Sepsis

refers to the

evidenced by :

loss & facilitate

metabolic

Temp: 36.4

Objective:

presence in a

Temp: 36.5 `C

the baby’s oral

rate and

(-) irritability; crying

Temp: 38.9’C

newborn baby

(-) irritability

intake.

Diaphoresis

(-) flushed skin

(+) flushed skin

of a bacterial

(-) flushed skin

>Promote bed

>Reduces

(+) irritability;

blood stream

rest.

body heat

Crying

infection (BSI)

production.

(such as

>Maintain IV

meningitis,

fluids as ordered dehydration

pneumonia,

by physician.

pyelonephritis,

>Administer

or

Anti-pyretic or

>Reduces

gastroenteritis)

antibiotic drugs

fever and

in the setting

as ordered.

treats

of fever. Older

>>Prevents

underlying

textbooks may

>Monitor

cause.

refer to

hematologic

>Indicates

neonatal

tests and other

presence of

sepsis as

pertinent lab

infection and

"sepsis

records.

dehydration

neonatorum".

ASSESSMENT S: “Walang gana dumede ang anko ko, mainit at matamlay” as verbalized by the mother. O:  Flushed skin  Warm to touch  Body malaise  Restlessnes s  Vital sign as follows: T:38.9 C HR:174bpm RR:64cpm

NURSING DIAGNOSIS Risk for infection related to compromise d immune system.

SCIENTIFIC BASIS Sepsis is a clinical term used to describe symptomatic bacteremia, with or without organ dysfunction. Sustained bacteremia, in contrast to transient bacteremia, may result in a sustained febrile response that maybe associated with organ dysfunction. Septicemia refers to the active multiplication of bacteria in the bloodstream that results in an

GOAL/ NURSING OBJECTIVES INTERVENTION After 8 hours of INDEPENDENT: nursing  Provide isolation intervention the and monitor patient would be visitors as free from any indicated. signs and symptoms of infection.



Wash hands before or after each care activity, even gloves are used.

RATIONALE 

Body substance isolation (BSI) should be used for all infectious patients. Reverse isolation/restric tion of visitors may be needed to protect the immunosuppr essed patient.



Reduces risk of cross contamination because gloves may have noticeable defects, get torn or damaged during use.

EVALUATION After 8 hours of nursing intervention the patient manifest free from any signs and symptoms of infection.

overwhelming infection.



Limit use of invasive devices or procedure as possible.



Prevents spread of infection via airborne droplets.



Inspect wounds or site of invasive devices, paying particular attention to parenteral lines.



May provide clue to portal entry, type of primary infecting organisms, as well as early identification secondary infection.



Maintain sterile technique when changing dressings, suctioning or providing site care.



Prevents introduction of bacteria, reducing risk of nosocomial infection.



Provide tepid sponge bath and avoid use of alcohol.



Used to reduce fever.



Observe for chills and profuse diaphoresis.



Chills often precede temperature spikes in presence of generalized infection.



Monitor for signs of deterioration of condition or failure to improve in therapy.



May reflect inappropriate antibiotic therapy or overgrowth of secondary infections.

DEPENDENT: 

Obtain specimens of urine, blood, sputum, wound as indicated for gram stain, and sensitivity.



Identification of portal entry and organism causing the septicemia is crucial ineffective treatment.



Administer antibiotics as prescribed.



To prevent further spread of infection

ASSESSMENT S: O:  Decreased urine output 

Increased urine conce ntration



Increased pulse rate (above 160 bpm)



Decreased body temperature (above 36 oC)



Decreased skin turgor



Dry skin/ mucous membranes



Elevated

NURSING DIAGNOSIS

SCIENTIFIC BASIS Fluid volume Fluid deficit, volume or hypovolem deficit relate ia, occurs from a loss of d to failure body fluid or of regulatory the shift of fluids into the mechanism third space one factor includes a failure of the regulatory mechanism of the newborn specifically hyperthermia

GOAL/ OBJECTIVES After 8 hours of

NURSING INTERVENTION INDEPENDENT:

nursing



Monitor and record vital signs





Note for the causative factors that contribute to fluid volume deficit





Provide TSB if patient has fever.





Provide oral care by moistening lips & skin care by



intervention patient will be

RATIONALE

able to maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor and prompt capillary refill and resolution

EVALUATION

After 8 hours of nursing intervention To note for patient was the alterations in able to maintain fluid V/S volume at a (decreased functional level BP, Increased in as evidenced by individually PR and adequate temp) urinary output with normal To assess specific gravity, what factor stable vital contributes signs, moist to fluid mucous volume membranes, deficit that good skin may be given prompt turgor and prompt intervention capillary refill To decrease and resolution temperature and provide comfort To prevent injury from dryness

hct

providing daily bath.

of edema.

DEPENDENT: 

Administer IV fluid replacement as ordered



Administer antipyretic drugs if patient has fever as ordered



Replaces fluid losses



To reduce body temperature