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ASSESSMENT NSG SCIENTIFIC GOAL/OBJECTIVES NSG.

RATIONALE EVALUATION
DIAGNOSIS BASIS INTERVENTION
Subjective: Impaired Neonatal After 8 hours of >Assess >Manifestation After 8 hours of
“Maglisod na gas pneumonia is nursing respiratory rate, of respiratory proper nursing
siyag hinga” as exchange lung infection interventions, the depth and distress is intervention, the pt
verbalized by related to in a neonate. patient will achieve a Heartrate of dependent on has achieved a
the mother. thick Onset may be timely resolution of patient. indicative of timely resolution of
mucous within hours current infection the degree of current infection
Objective: secretions of birth and without complication. lung without negative
> Dyspnea Secondary part of a A.) The pt will have a involvement. complication as
>Tachycardia to Neonatal generalized normal rate of rr to >Monitor the >High fever eveidenced by:
>Irritability Pneumonia sepsis 50 from 64 cpm. body greatly (-) Tachycardia PR-
RR: 64 cpm syndrome or B.)The pt will have a temperature. increase 130bpm
PR:170 bpm after 7 days normal beating from metabolic (-)Dyspnea RR-
and confined 170 bpm to 130 bpm. demand and 50cpm
to the lungs. C.) The patient will oxygen (-)Irritability
Signs may be have arelief from consumption.
limited to irritability as >Elevate head > To provide
respiratory evidence by the of the Patient. comfort for the
distress or infants sleep. >Encourage patient.
progress to mother to do >To easily
shock and postural facilitate
death. drainage on secretion from
Diagnosis is patient. the patient.
by clinical and >Assist with >Facilitates
laboratory nebulaizer liquification
evaluation for treatments care and removal
sepsis. of pulmo. of secretions.
>Have meds
given to pt as >Drugs used
prescribed by to combat
the AP. most of the
mincrobial
pneumonia.
ASSESSMENT NSG. SCIENTIFIC GOAL/OBJECTIVE NSG. RATIONALE EVALUATION
DIAGNOSIS BASIS INTERVENION
Subjective: Risk for Parenting is The mother will >Interview >To know The mother will
“Dili nako kbalo providing a identify and parents, noting what the identify and
Impaired
unsay hmuon nako nurturing and demonstrate parents demonstrate
Parenting their
inig gawas namo constructive techniques to feelings about techniques to
perception of
drias hospital.” related to environment enhance behavioral the situation. enhance
situational and
disease that promotes organization of the behavioral
Objective: growth and neonate
individual organization of
process of
>Fearful development After discharge the concerns the neonate
newborn >Educate
>Irritable in a child or parents will be able Helps clarify After discharge
Secondary children to have a mutually parents realistic the parents will
to Neonatal satisfying regarding child expectations be able to have a
interactions with mutually
Sepsis. growth and
their newborn. satisfying
development,
interactions with
addressing
their newborn
parental negative from
perceptions fearfulness.
>Involve >Enhances
parents in self-concept
activities with
the newborn
that they can
accomplish
successfully
>Recognize >Reinforces
and provide continuation
positive of desired
feedback for behaviors
nurturing and
protective
parenting
behaviors
ASSESSMENT NURSING SCIENTIFIC GOAL/OBJECTIVES NURSING RATIONALE EVALUATION
DIAGNOSIS BASIS INTERVENTION
Subjective:”Init Hyperthermia Neonatal After 2 hours of >Provide Tepid >Enchances After 2 hours of
kayo siya knina related to sepsis is a comprehensive Sponge bath. heat loss by comprehensive
murag on and infection type of Nursing Intervention, evaporation intervention the pt
off iyng fever.” process neonatal the patient will lower and has been free from
As verbalized Secondary to infection and down its body temp conduction . hyperthermia as
by the mother. Neonatal specifically to normal level as >Assess fluid >Increases evidenced by:
Sepsis refers to the evidenced by : loss & facilitate metabolic Temp: 36.4
Objective: presence in a Temp: 36.5 `C the baby’s oral rate and (-) irritability; crying
Temp: 38.9’C newborn baby (-) irritability intake. Diaphoresis (-) flushed skin
(+) flushed skin of a bacterial (-) flushed skin >Promote bed >Reduces
(+) irritability; blood stream rest. body heat
Crying infection (BSI) production.
(such as >Maintain IV >>Prevents
meningitis, fluids as ordered dehydration
pneumonia, by physician.
pyelonephritis, >Administer
or Anti-pyretic or >Reduces
gastroenteritis) antibiotic drugs fever and
in the setting as ordered. treats
of fever. Older underlying
textbooks may >Monitor cause.
refer to hematologic >Indicates
neonatal tests and other presence of
sepsis as pertinent lab infection and
"sepsis records. dehydration
neonatorum".
ASSESSMENT NURSING SCIENTIFIC GOAL/ NURSING RATIONALE EVALUATION
DIAGNOSIS BASIS OBJECTIVES INTERVENTION
S: “Walang gana Risk for Sepsis is a After 8 hours of INDEPENDENT: After 8 hours of
dumede ang infection clinical term nursing  Provide isolation  Body nursing
anko ko, mainit at related to used to intervention the and monitor substance intervention the
matamlay” as compromise describe patient would be visitors as isolation (BSI) patient
verbalized by the d immune symptomatic free from any indicated. should be manifest free
mother. system. bacteremia, signs and used for all from any signs
with or without symptoms of infectious and symptoms
O: organ infection. patients. of infection.
 Flushed dysfunction. Reverse
skin Sustained isolation/restric
 Warm to bacteremia, in tion of visitors
touch contrast to may be
 Body transient needed to
malaise bacteremia, protect the
 Restlessnes may result in a immunosuppr
s sustained essed patient.
 Vital sign as febrile
follows: response that
T:38.9 C maybe  Wash hands  Reduces risk
HR:174bpm associated before or after of cross
RR:64cpm with organ each care activity, contamination
dysfunction. even gloves are because
Septicemia used. gloves may
refers to the have
active noticeable
multiplication defects, get
of bacteria in torn or
the damaged
bloodstream during use.
that results in
an
overwhelming  Limit use of  Prevents
infection. invasive devices or spread of
procedure as infection via
possible. airborne
droplets.

 Inspect wounds or  May provide


site of invasive clue to portal
devices, paying entry, type of
particular attention primary
to parenteral lines. infecting
organisms, as
well as early
identification
secondary
infection.

 Maintain sterile  Prevents


technique when introduction
changing of bacteria,
dressings, reducing risk
suctioning or of nosocomial
providing site care. infection.

 Provide tepid  Used to


sponge bath and reduce fever.
avoid use of
alcohol.
 Observe for chills  Chills often
and profuse precede
diaphoresis. temperature
spikes in
presence
of generalized
infection.

 Monitor for signs  May reflect


of deterioration inappropriate
of condition or antibiotic
failure to improve therapy or
in therapy. overgrowth
of secondary
DEPENDENT: infections.

 Obtain specimens  Identification


of urine, blood, of portal entry
sputum, wound as and organism
indicated for gram causing the
stain, and septicemia is
sensitivity. crucial
ineffective
treatment.

 Administer  To prevent
antibiotics as further spread
prescribed. of infection
ASSESSMENT NURSING SCIENTIFIC GOAL/ NURSING RATIONALE EVALUATION
DIAGNOSIS BASIS OBJECTIVES INTERVENTION
S: Fluid Fluid volume After 8 hours of INDEPENDENT: After 8 hours of
O: deficit, nursing
 Decreased volume or hypovolem nursing  Monitor and  To note for intervention
urine output deficit relate ia, occurs intervention record vital the patient was
from a loss of signs alterations in able to
d to failure body fluid or patient will be maintain fluid
 Increased V/S
of regulatory the shift of able to maintain (decreased volume at a
urine conce fluids into the BP, functional level
mechanism fluid volume at a
ntration third space Increased in as evidenced
one factor functional level PR and by individually
 Increased includes a adequate
as evidenced by temp)
pulse failure of the urinary output
regulatory individually with normal
rate (above  Note for the  To assess
mechanism adequate causative what factor specific gravity,
160 bpm) of factors that contributes stable vital
urinary output
 Decreased the newborn contribute to fluid signs, moist
specifically with normal to fluid volume volume mucous
body hyperthermia membranes,
specific gravity, deficit deficit that
temperature may be good skin
stable vital
(above 36 given prompt turgor and
signs, moist intervention prompt
oC) capillary refill
mucous
 Decreased  Provide TSB if  To decrease and resolution
membranes, patient temperature
skin turgor
good skin turgor has fever. and provide
 Dry skin/ comfort
and prompt
mucous
capillary refill  Provide oral  To prevent
membranes care by injury from
and resolution
 Elevated moistening lips dryness
& skin care by
hct of edema. providing daily
bath.

DEPENDENT:

 Administer IV  Replaces
fluid fluid losses
replacement as
ordered

 Administer  To reduce
antipyretic body
drugs if patient temperature
has fever as
ordered