S.No 1.

Nursing Assessment Assess the child.

Observe the vital signs through cardiac monitor. Respiratory rate is high 170 BPM.

Nursing Diagnosis Ineffective breathing pattern related to disease condition.

Expected outcome Airway remains patent

Nursing Interventions Planning Implementation To provide the Provided the comfortable comfortable position for position for optimum air optimum air exchange. exchange. To do suction remove secretions. Closely monitor blood gas measurement, tCO2 and Spo2 reading. To apply and manage monitoring equipment correctly. To observe and assess childs response to ventilation and oxygen level. Provided the prone position for proper V/Q matching. Suctioning done with aseptic technique with other sister help. Secretions color and quantity noted in nursing chart. Closely monitored blood gases measurement, tco2 and spo2 reading and recorded. Checked the ventilators tubing, alarms, fill the sterile water in humidifier and managed the equipment correctly. Observed and assessed childs response to ventilation and oxygen level through monitors.

evaluation Oxygen level normal and breathing pattern is better.

Spo2 level is lower range 85 on 60% oxygen.

S.No

Nursing Assessment Assess the child Checked the auxiliary temperature 36c. Child skin is cold.

Nursing Diagnosis Ineffective thermoregulation related to immature temperature control and decreased subcutaneous body fat.

Expected outcome Childs auxiliary temperature remains within normal range.

Planning

Nursing Interventions Implementations Kept the baby in the incubator.

Evaluation

2.

Keep the baby in incubator, temperature sensor keep in 37c37.5c.

Maintain the normal temperature range to the baby.

To cover the baby to 2- Kept the incubator on servo 3 sterile sheet. control mode on 37c37.5c. temperature.

To open the incubator when necessary.

Minimum open the incubator.

To check the temperature by auxiliary again

Checked the temperature by auxiliary and recorded.

S.No

Nursing Assessment Assess the childs all invasive line.

Nursing Diagnosis High risk for infection related to deficit immunologic defenses.

Expected outcome Will exhibit no evidence of nosocomial infection

Planning

Nursing Interventions Implementations

Evaluation

3.

To ensure that all Ensured that all caregiver caregiver wash hands wash hands before and before and after touching after touching the baby. the baby. To ensure the all equipment clean and sterile which connect with baby. To administer antibiotics as per treatment chart. To allow the minimum visitors. To give Health teaching to the parents about infection control and waste management Ensured the all equipment clean and sterile which connect with baby.

Nosocomial infection chances will be reduces.

Given the antibiotics as per treatment chart. Allowed the minimum visitors Given Health teaching to the parents about infection control and waste management

S.No

Nursing Assessment Assess the child Child is low birth weight. Patient cant feed due to treatment procedures and disease condition.

Nursing Diagnosis Altered nutrition less than body requirement related to disease condition and immaturity.

Expected outcome Baby receive an adequate amount of calories and essential nutrients.

Planning

Nursing Interventions Implementations Maintained the total parenteral nutrition therapy. Monitored for signs of intolerance to TPN theraphy such as glucose level, protein level etc. Checked and try for orogastric tube feeding. Checked the baby weight daily each shift and recorded. Maintained the intake output chart and recorded. Checked the serum protein level daily and recorded.

Evaluation

4.

To maintain the total parenteral nutrition therapy. To monitor for signs of intolerance to TPN theraphy. To check and try for orogastric tube feeding. To check the baby weight daily each shift. To maintain the intake output chart. To check the serum protein level daily.

Nutrition status will be improve.

S.No

Nursing Assessment Communicate with parents. Parents look anxious and tensions about babys disease condition.

Nursing Diagnosis Anxiety and fear related to babys hospitalization in ICU.

Expected outcome Anxiety and fear will reduce.

Planning

Nursing Interventions Implementations Communicated with parents. Explained about all procedure to the parents. Provided the psychological support. ventilated the parents. called the parents in ICU if need. Showed the baby to the mothers.

Evaluation

5.

To communicate with parents. To explain about all procedure to the parents. To provide the psychological support. To ventilates the parents. To call the parents in ICU if need. To show the baby to the mothers.

Anxiety and fear reduce.

Nursing Care Plan