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Nursing Dx 1.

Ineffective airway clearance r/t tracheomalacia, developmental


delay, and decreased respiratory capacity aeb coarse breath sounds, cough, and
thick, yellow/green mucous brought up with suctioning.
Outcome: The pt. will display a patent airway with no s/sx of worsening
condition or respiratory distress by 9/9/15 at 1400.

Rationale:
Suctioning will
mechanically clear
the airway to allow
for patency for the
pt. who is unable to
do so because of an
ineffective cough.

Monitor for decreasing oxygen


saturations, mucous production,
cough, lung sounds, and respiratory
effort.

Nursing collaboration and


communication with physical
therapist in developing plan
of care

No
meds
for dx

r/t
developmental
delay and

No Meds for
this condition

Nursing Dx 2: Impaired skin integrity r/t


incontinence & stasis of drainage aeb dry, flaky
skin, rash around rectum.
Outcome: The pt. will show decreased redness
and drainage at sore around rectum by 9/9/15 at

Evaluation:
Goal partially
met.

Rationale
: Urine and
feces can
accumulat
e to cause
further
irritation

r/t
developm
ent delay
causing
lack of
mobility

Check diaper Q1 and


change when wet or
soiled.

Care Concept: Developmental delay


secondary to congenital heart disease
with ECMO, tracheomalacia, hx aortic &
femoral vein thrombus, congenital

Development
delay results
from results of
care concepts

Rationale: This helps to achieve


the goal using positive
reinforcement.

Offer praise and favorite toy


as reward when some prone
positioning was achieved.

Meds: topical
Destin with
stomahesive
applied to
rectal area
PRN with
every diaper
change.

Assessment data: dime sized beefy


red rash noted around rectum with
small amounts of brown drainage, dry,
flaky skin noted on arms, legs, and

Topical meds
not weights
based
Not reaching
milestones
r/t 16
months of
age- plots
out in infant
stages, not
toddler

Nursing Dx 3: Delayed Development r/t


hospitalization since birth & effects of
physical disability aeb inability to meet
toddler developmental milestones in gross
motor, fine motor, and communication.
Outcome: The pt. will tolerate 2 minutes

Use towel to raise head


while lying prone

Elevate head,
sit up with
boppy pillow,
and change
position

Suction PRN for oxygen saturation <90%,


gurgling sounds, and worsening breath
sounds on auscultation.

Rationale: PT can
provide specific
knowledge and tips for
helping with gross
motor ability in relation
to reaching

Rationale: Decreases anxiety of


laying completely flat on the
ground but still slows for prone
positioning

Assessment data: coarse breath sounds in right and left lobes


during inspiration and expiration that does not clear with coughing,
trach 4.0 pediatric bivona cuffless with PRN humidified trach collar
21-28% oxygen, non-productive cough with thick, yellow/green
secretions requiring PRN suctioning

Rationale: Keeping the head


elevated will promote chest
expansion and mobilization of
mucous to allow for a patent airway.

Rationale: Decreased airflow from


mucous accumulation will result in
desaturation, adventitious breath
sounds, and an increase in respiratory
effort. A change from baseline will
indicated the need for further

Evaluati
on: Goal
not met.

Evaluatio
n: Goal
met.

Developmental
data: Erickson=
Autonomy v. shame
& doubt based on
age, Denver II= plots
at 3 month gross
motor, 1 month
language, 9 months
fine motor, 5 months

Weight=
9.3kg

Assessment data: non-verbal, no verbal


cues made, transfers objects between
hands, pincher grasp intact, and imitates
sounds and movements. solitary play in
crib, interaction with toys and noises, able
to hold head up independently,
independently sits without support, able
to roll from prone to supine but not supine

Rationale: This
allows for
evaluation of
interventions, if
improvement has
occurred, and
written records for
the interdisciplinary
Assess wounds
and document
characteristics.

Rationale: These contain


ingredients to help the healing
process and prevent further skin
irritation.
Apply medications as
ordered with each diaper
change- Destin with
stomahesive.

KEY:
Nursing dx with
outcome
Assessment
data
Intervention
Evaluation
Meds
Weight data
Developmental

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