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.
No
meds
for dx
r/t
developmental
delay and
No Meds for
this condition
Evaluation:
Goal partially
met.
Rationale
: Urine and
feces can
accumulat
e to cause
further
irritation
r/t
developm
ent delay
causing
lack of
mobility
Development
delay results
from results of
care concepts
Meds: topical
Destin with
stomahesive
applied to
rectal area
PRN with
every diaper
change.
Topical meds
not weights
based
Not reaching
milestones
r/t 16
months of
age- plots
out in infant
stages, not
toddler
Elevate head,
sit up with
boppy pillow,
and change
position
Rationale: PT can
provide specific
knowledge and tips for
helping with gross
motor ability in relation
to reaching
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
Rationale: This
allows for
evaluation of
interventions, if
improvement has
occurred, and
written records for
the interdisciplinary
Assess wounds
and document
characteristics.
KEY:
Nursing dx with
outcome
Assessment
data
Intervention
Evaluation
Meds
Weight data
Developmental