Anda di halaman 1dari 11

ASSESSMENT

NURSING DIAGNOSIS

GOAL

INTERVENTION

IMPLEMENTATION

EVALUATION

Subjective data: The child mother Altered complaints her baby have To minimize Assess the intracranial pressure Maintain adequate cerebral perfusion Provide the based care Assessed the intracranial pressure Maintained adequate cerebral perfusion Provided the based care Promoted the rest sleep

Maintain the

cerebral tissue the tissue perfusion related to perfusion and relief from

Objective data: It has been observed by patient condition

head injury or respiratory increased intracranial pressure problems

Promote the rest & Provided adequate sleep Provide adequate nutrition nutrition

ASSESSMENT Subjective data: The child there told that the baby take the durocentry movement Objective data: It has been observed that by complaints

NURSING DIAGNOSIS Risk for injury related to convulsions and alteration of consciousness

GOAL

INTERVENTION

IMPLEMENTATION

EVALUATION

Assess the level of Preventing consciousness from injury Constant observations for restlessness Observations for involuntary movements and convulsions. administer the anticonvulsive drugs and allowing attendance Removal of hard object sharp things or toys from the child

Assessed the level of To meet the goals consciousness Constant observations for restlessness Observed for involuntary movements and convulsions. Administered the anticonvulsive drugs and allowing attendance Removal of hard object sharp things or toys from the child

ASSESSMENT Subjective data: The child mother complaints her baby have difficulty to breath. Objective data: It has been observed that by patient condition

NURSING DIAGNOSIS In effective airway clearance due to upper airway obstruction

GOAL

INTERVENTION

IMPLEMENTATION

EVALUATION

Assess the general To prevent condition of the the airway child obstruction Positioning with extended head or head turned to one side to deain respiratory secretions Provide the oxygen therapy by hood or beg mask Prepare for endotracheal intonation or tracheostomy or mechanical ventilation

Assessed the general condition of the child Provide the obstructive Provided comfortable position, semi fowlers position. Provided the oxygen therapy by hood or beg mask Prepared for endotracheal intonation or tracheostomy or mechanical ventilation

ASSESSMENT Subjective data: The child mother told that his/her baby having the anorenic

NURSING DIAGNOSIS Altered hydration related to unconsciousness

GOAL Maintain the normal nutritional status

INTERVENTION Assess the general condition of the child Assess the normal nutritional status of the child Encourage to take small and frequent diet Provide health education to the present about high catogary and energy diet Encourage to take more fluids

IMPLEMENTATION

EVALUATION

Objective data: It has been observed that by checking weight

Assessed the general condition of the To maintain the child Assessed the normal normal nutritional nutritional status of state weight the child Encouraged to take small and frequent diet Provided health education to the present about high catogary and energy diet Encouraged to take more fluids

ASSESSMENT

NURSING DIAGNOSIS

GOAL

INTERVENTION

IMPLEMENTATION EVALUATION

Subjective data: Impairment of Improvemen Assess the general verbal t of variable condition of the patient Provide the comfortable bed to the child Improve the communication skills Provide the speech therapy Maintain the good communication with the child & their parents communicatio communicat n secondary to weakness or paralysis of the muscles involved in providing Objective data: speech ion

Assessed the general condition of the patient Provided the comfortable bed to the child Improved the communication skills Provided the speech therapy Maintained the good communication with the child & their parents

Improve the communication skills

ASSESSMENT

NURSING DIAGNOSIS

GOAL

INTERVENTION Assess the general condition of the diet Assess the sleeping pattern of the child Provide calm environment Encourage to take hot milk or hot water before going to bed. Administer the sedative according to doctor prescription

IMPLEMENTATION Assessed the general condition of the diet Assessed the sleeping pattern of the child Provided calm environment Encouraged to take hot milk or hot water before going to bed. Administered the sedative according to doctor prescription

EVALUATION

Subjective data: Sleeping disturbance related to surgical procedure and injury Objective data:

To provide normal sleeping pattern

Maintained the normal sleeping pattern

ASSESSMENT

NURSING DIAGNOSIS Risk for impaired skin integrity related to enlarged to head

GOAL

INTERVENTION Assess the general condition of the child Assess the skin integrity of the child Administer the medication according to doctor prescription Provide the skin care and provide the daily bath Advice to maintain the personal hygiene Provide the health education to the parent about the personal hygiene

IMPLEMENTATION EVALUATION Assessed the general Reduce the skin integrity condition of the child Assessed the skin integrity of the child Administered the medication according to doctor prescription Provided the skin care and provide the daily bath Adviced to maintain the personal hygiene Provided the health education to the parent about the personal hygiene

Subjective data:

Maintain the normal skin integrity

Objective data:

ASSESSMENT

NURSING DIAGNOSIS

GOAL

INTERVENTION IMPLEMENTATION

EVALUATION

Subjective data:

Anxiety related To provide to the abnormal the condition and surgical intervention information regarding the surgical intervention

Assess the general condition of the child ventilate the feelings Provide the deformation

Assessed the general condition of the child ventilated the feelings Provided the deformation regarding the surgical intervention Provided the psychological support Provided the spiritual support

To ventilate the feelings

Objective data: If has been observed by parental anxiety

regarding the surgical intervention Provide the psychological support Provide the spiritual support

ASSESSMENT

NURSING DIAGNOSIS Hyperthermia related to disturbance of brain function

GOAL

INTERVENTION Assess the general

IMPLEMENTATION

EVALUATION

Subjective data: The patient says that child having the high temperature and references

To maintain the normal body temperature & breath function

condition of the child Monitor the vital signs Provide the cold sponges Administer the

Assessed the general Monitored the vital signs Provided the cold sponges Administered the antipyretics Maintained the normal fluid and electrolyte balance to administer the I.V fluids Provided the rest & sleep

To reduce the

condition of the child temperature

Objective data: It has been observed that pyremia by checking vital signs

antipyretics Maintain the normal fluid and electrolyte balance to administer the I.V fluids Provide the rest & sleep

ASSESSMENT

NURSING DIAGNOSIS Ineffective family coping related to life threating problems of infant

GOAL

INTERVENTION

IMPLEMENTATION

EVALUATION

Subjective data:

To provide Assess the the awareness general condition of the child Provide the emergency care to the child Ventilate the

Assessed the general condition of the child Provided the emergency care to the child Ventilated the parent feeling and child feelings Clarified the parent doubt about their child condition

Improve the family coping skills

Objective data:

parent feeling and child feelings Clarify the parent doubt about their child condition

NURSING DIAGNOSIS
Altered cerebral tissue perfusion related to head injury or increased intracranial pressure Risk for injury related to convulsions and alteration of consciousness In effective airway clearance due to upper airway obstruction Altered hydration related to unconsciousness Impairment of verbal communication secondary to weakness or paralysis of the muscles involved in providing speech Sleeping disturbance related to surgical procedure and injury Risk for impaired skin integrity related to enlarged to head Anxiety related to the abnormal condition and surgical intervention Hyperthermia related to disturbance of brain function Ineffective family coping related to life threating problems of infant