VIII.

NURSING CARE PLAN

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Subjective: Ineffective Breathing -Within first hour, -Closely -To act as the -Within 1 hour of
Pattern related to the baby’s monitoring of the baseline data for nursing
“ Marigrigatan
temporary asphyxia respiratory rate vital signs further intervention, the
nga aganges tuy
as evidenced by should be at least especially the RR. management. baby’s RR
anak ko” as
double cord coil upon 30-40 cpm/minute increased to 32
verbalized by -Regulate oxygen - To provide
delivery cpm/ minute
the mother as prescribed by sufficient amount
the physician. of oxygen to the
Objective: -Within 8 hours of
baby.
duty, the baby’s RR - Instructed -Within 8 hours of
-Slow and
should be in a mother to - For easier lung nursing
irregular
stable rate- 30-50 maintain a semi- expansion/ interventions,
breathing
cpm/minute fowler’s position breathing baby’s RR is in
-RR= 28 most of the time. stable rate ranging
cpm/minute from 40-60
cpm/minute.

Objective: Hyperthermia related - Within first two - Closely monitor -to serves as a -After 2 hours of
to infection as hours of duty, the vital signs baseline data. doing nursing
-Temp. 38.2
evidenced baby’s temp should especially interventions,
degrees Celsius by temperature 38.2 decrease to 37.5 tempearture and baby’s temp
orally and high WBC degrees Celsius
-hot from 38.2 degrees report any decreased to 37. 6
flashes/skin celsius. unusual result. from 38.2.

-lethargic -Within 8 hours of -perform TSB if -to help lower the

duty, baby’s temp needed. temperature.
-After 8 hours of
should maintain a
-Administer -to help lower the doing nursing
normal
paracetamol as temperature. interventions,
temperature which
prescribed by the baby’s temp is
is 36.5-37.4.
Physician. stable, normal
temp is
- initiate -to prevent maintained in a
breastfeeding dehydration. range of 36.8-37.2.
unless
contraindicated.
 IX. DRUG STUDY
Classification: AMINOGLYCOSIDE ANTIBIOTIC
Generic Name: GARAMYCIN
Brand Name: GENTAMYCIN
Doctors Order: 2.1ml q 12 hours
Action
Broad-spectrum
aminoglycoside derived from
Micromonasporapurpurea.
Action is usually
bacteriocidal
Indication Contraindication Side Effects Nursing Consideration
Has been used History of Nausea -Monitor for any signs
effectively in hypersensitivity to Vomiting of allergic reactions and
combination with or toxic reaction Stomach upset report immediately to
with Loss of appetite
carbenicillin for the the physician.
anyaminoglycoside Injection site
treatment of lefe- antibiotic. Safe use reactions(pain, -Monitor for any
threatening during pregnancy irritation, and
serious side effects.
infection caused be ( category C) or redness)
Pseudomonas lactation is -Administer medication
aeruginosa. It has established.
on time as prescribed
also been found by the Physician.
effective when used
in conjunction with
a penicillin-type
drug of endocarditis
caused by group D
streptococci.