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Assessment Nursing Diagnosis Objective Intervention Rationale Evaluation

Subjective: Risk for Infection is Patient significant -Assess for The patient
possibly evidenced others will identify presence of host- significant others
Objective: by risk factors of Intervention to specific factors that can identify how to
inadequate primary prevent the risk of affect immunity: prevent infection.
defenses infection.
Extremes of -newborns are
Age more susceptible to
disease and
infection than the
general population
- Malnutrition
weakens the
immune system
-Monitor the clients
-to limit exposures,
visitors and
thus reducing
caregivers for
-This reduces the
-Provide for
risk of
insolation, as

-Administer/ monitor
-to determine
effectiveness of
therapy or presence
of side effects.

Assessment Nursing Diagnosis Objective Intervention Rationale Evaluation

Subjective: Risk for ineffective Patient significant -Collaborative in the -to correct or treat The patient
Gastrointestinal others will have treatment of that could affect GI significant other
Objective: perfusion possibly understanding of underlying perfusion have understanding
evidenced by risk condition, therapy conditions of the condition,
factors of persistent regimen and when therapy regimen
fetal circulation and to contact -Administer -to reduce the and when to have a
exchange problem healthcare provider. prescribed potential for stress- contact healthcare
prophylactic related GI provider
medications in at- complication
risk clients during
illness and

-Discuss individual This is information

risk factors as necessary for the
appropriate client to make
informed choices
about remedial risk
factors and commit
to lifestyle changes

-Emphasize the -This is important

importance of for effective disease
routine follow-up management and
and laboratory possible changes in
monitoring as therapeutic regimen
Assessment Nursing Diagnosis Objective Intervention Rationale Evaluation
Subjective: Impaired Patient will -Evaluate ABGs - to determine Patient reestablish
spontaneous reestablish and and/or pulse presence and and can maintain
Objective: Ventilation may be maintain respiratory oximetry and degree of arterial respiratory pattern
related to pattern via capnography hypoxemia via ventilator with
respiratory muscle ventilator with the absence of
fatigue absence of -Review serial -to diagnose retractions
retractions chest x-rays and underlying disorder
imaging magnetic and monitor
resonance imaging/ response to
computed treatment
tomography scan

-observe overall -client may be

breathing pattern, completely
distinguishing dependent on the
between ventilator or able to
spontaneous take breaths but
respiratory and poor oxygen
ventilator breaths saturation without
the ventilator

-Verify that clients -Decrease work of

respiration are in breathing;
phase with the maximizes O2
ventilator delivery
Assessment Nursing Diagnosis Objective Intervention Rationale Evaluation
Subjective: Risk for impaired Patient significant -Identify the infants -Each child is born The patient
Attachment is others will engage strengths and with his significant other
Objective: possibly evidenced in mutually vulnerabilities temperament that engage in mutually
by risk factors of satisfying affects interaction satisfying
premature interaction with with caregivers interaction with
child child
-Educate parents -This helps to clarify
regarding child realistic or
growth and unrealistic
developing, expectations

-Assist parent in -To provide

modifying the appropriate
environment stimulation

-Involve parents in -This promotes a

activities with the sense of
child that they can confidence, thus
accomplish enhancing self-
successfully concept