Assessment Nursing Scientific Nursing goal Nursing Rationale evaluation

diagnosis background intervention

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