REGION 1 MEDICAL CENTER
ASSESMENT
Subjective:
NURSING DIAGNOSIS
PLANNING / OUTCOME
INTERVENTION
RATIONALE
Provides a basis for evaluating adequacy of ventilation Use of accesory muscle in respiration may occur in response to ineffective ventilation Crackles indicate accuymulation of secretions and inability to clear airways
EVALUATION
GOAL MET During the shift the patient able to maintain airway as evidenced by normal respiration as evidenced by absence of dyspnea ans adventitious sound, absence of bronchial secretions, allay restlessness
Inefrfective airway clearance related to increased production of Objective: brochial secretions secondary to fluid shift to extravascular Abnormal breath sounds: compartment wet crackles on left and right lungs Dyspnea: use of accesory muscle when respiration (elevated shoulder) increased in respiratory rate: 67 cpm restlessness
During the shift the patient Assessed respiratory rate will be able to maintain airway as evidenced by normal respiration as Checked used of accesory muscle evidenced by absence of dyspnea ans adventitious sound, absence of bronchial secretions, allay restlessness Auscultated thebreath sound: note areas presences with adventitious sound
Document the respiratory secretions Expectarations may be different : the characteristic and amount of when secretions are very thick sputum Maintained the patient on moderate Positioning helps maximized high backrest lung expandsion Checked for obstruction: accumulation of secretions To maintain adequate airway patency
Suction patient limited to 5 second duration should limited to duration reduced hazard of hypoxia, damage airway mucosa and impair cilia action Administer medication as indicated: Increased lumen size of the Broncidilator thracheobronchial tree, thus decreasingresistance to airflow and improving oxygen delivery
Submitted by: Gladys G. Masaoy RN HEALS Cecilia A. De Guzman NICU Senior Nurse
REGION 1 MEDICAL CENTER
ASSESMENT
Objective: Warm to touch Clammy skin Sweating Pallor Tachycardia VS as follows T: 38.2 PR: 68 RR: 45
NURSING DIAGNOSIS
Ineffective thermoregulation; Hyperthermia related to immune compensation for changes in the enviromental temperature and presence of endogenous
PLANNING / OUTCOME
SHORT TERM
INTERVENTION
INDEPENDENT
RATIONALE
EVALUATION
Goal Met:
After 10-30 mins of Asses neurological response, reaction to stimuli , nursing intervention pupils and presence of posturing seizure the newborn will prevent gaining heat as Asses of envirement for possible source of heat evedenced by absence gain of profuse sweating Monitor vital sign LONG TERM After 4 hours of Note presence/ absence of sweating nursing intervention the neonate will able to maintain normal Provide tepid sponge bath but avoid using alcohol temperature and prevent infection as evedence by absence of fever promote surface cooling by undressing or not double wrapping the infant Observe aseptic technique in giving care
For proper assessment to the severity of problem to minimized risk of heat gain To monitor significant changes in vital sign
SHORT TERM After 10-30 mins of nursing intervention the newborn was able prevent gaining heat as evedenced by absence of profuse sweating
Evaporation is decreased by eviromental factor or high LONG TERM humidity After 4 hours of nursing intervention the neonate May help reduce fever, ice water or alcohol may cause was able to maintain chill actually elevating temperature normal temperature and prevent infection as To promote heat loss in the body evedence by absence of fever To prevent develop or further development of infection To offset increased oxygen demand and consumption
Provide supplemental oxygen To prevent further heat gain Avoid infant contact with hot surfaces Monitor Flid intake through IV To Prevent dehydration
Submitted by: Gladys G. Masaoy RN HEALS Cecilia A. De Guzman NICU Senior Nurse
