Nursing Diagnosis:

Erikson: As a 6 m.o. infant, the patient is in the Trust VS. Mistrust stage in Nursing Diagnosis:
1. Imbalanced nutrition less than body
requirements, related to unwillingness to development. In this stage, the infant primarily looks towards the primary caregiver 2. Risk for Developmental Delay
eat, as evidenced by loss of weight. for stability in basic needs like food, comfort, and care. Success in the stage is based
on infants feelings of safety and security. The patient was not receiving adequate Outcome/Goal: Patient will demonstrate 3
Outcome/Goal: Patient will gain at least 0.2 kg/day nutrition and was not thriving compared to other infants in this stage. The mother developmentally appropriate skills by 1300.
did provide stability in comfort, and care though. The patient interacted well with
mother, smiled, made eye contact, and babbled to her, and was comforted when
she held him.
Assessment Data:
Premature birth (born at under
Interventions:
Assessment Data: 31 weeks gestation)
1. Schedule of 4-6 oz. every 4 hrs. Regular
Refluxing Not able to roll over on own.
and consistent feedings will help patient
maintain and gain weight. Refusing bottle Not able to transfer rattle from
2. Supplemental NG feedings (35mL/hr.). Low weight hand to hand.
These supplemental feedings will ensure Appears small and thin for age
the patient is getting adequate nutrition
and increase caloric intake.
3. Strict I/Os. Measuring and evaluating
intake and output will help health care Interventions:
providers a clear picture if the patient is 1. Stimulate patient with rattle and hand it to patient. This
getting enough intake compared to output. Problem/Reason for will help him gain practice transferring objects in hands.
seeking health care: 2. Put patient on stomach for tummy time. This will help
Failure to Thrive patient learn how to turn himself.
3. Talk and interact with patient. This will encourage the
patient to babble, interact back, and recognize own name.

Outcome evaluation:- Goal partially met. Patient did gain weight (0.19 kg/day),
- of meeting desired goal.
but fell (0.01 kg) shy Outcome evaluation: Goal partially met. Patient was able to recognize his own
Weight: name, made eye contacted and babbled, but was not able to transfer rattle from
- 5.31 kg one hand to another, or roll over on own during tummy time.

Nursing Diagnosis: Medications:

1. Knowledge deficit of caretaker.
Famotidine (Pepsid): ORDERED: 40 mg/5 mL
Outcome/Goal: Patients caretaker will be able to demonstrate a technique to (8mg/mL); 0.5 mg/kg x 5.125 kg = administered
stimulate a sucking reflex by 1300. dose of 2.56 mg. USUAL DOSAGE: >3 mo. to 1
Assessment Data: yr.: 0.5 mg/kg/dose 2x daily for up to 8 wks.
Patient has weak suck when THERAPEUTIC RANGE: Max dose 40 mg/dose.
feeding. Doses up to 1 mg/kg/dose 2x daily have been
Interventions: Mom does not stimulate reported.
1. Teach caretaker to take finger or nipple of sucking reflex before feeding.
Influenza Vaccine 2016-2017 (6-35 months) (PF)
bottle and stimulate around, and under patients Patient is not getting
(Fluzone Quad Pediatric): ORDERED: 0.25 mL
mouth. This will help elicit the sucking reflex. adequate intake. dose IM injection prior to discharge USUAL
2. Teach caretaker how to elicit rooting reflex by
DOSAGE: 0.25 mL/dose for a total of 1 or 2
rubbing cheek before feeding. This will help
doses, dependent upon vaccination history.
patient latch onto bottle more readily.
THERAPEUTIC RANGE: N/A
3. Teach caretaker how to use slower nipples to
make feeding easier on patient. This slower rate
will help stimulate the patients sucking reflex. Key:
Main Concept
Nursing Diagnosis & Outcome/Goal Outcome Evaluation Weight

Interventions with
Outcome evaluation: Goal met. Caregiver was able to demonstrate how to Rationales Assessment Developmental
stimulate sucking reflex on patient before feeding a bottle by 1300. Medications