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Assessme Nursing Nursing Nursing Rationale Outcome Actual

nt Diagnosis Goal Intervention Criteria Evaluation

SUBJECTIV Impaired After 24hrs *INDEPENDENT: -Tachypnea indicates After 24 hrs of Goal met.
E: Gas of nursing 1. Assess respiratory respiratory distress esp thorough nsg. Seen pt. lying
exchange intervention: status, noting signs of when respi are Intervention, on bed
As r/t patient will respiratory distress >75cpm/min after the patient was without the
verbalized immature be (e.g., tachypnea, nasal first 5 hours of life. able to breathe oxyhood.
by the pt pulmonary gradually flaring, grunting, Expiratory grunting normally
SO: “naa functioning weaned to retractions, rhonchi, or represents attempt to without
na’y oxygen room air and crackles). maintain alveolar supplemental
nga breathe expansion; nasal flaring oxygen.
nakataod sa normally is a compensatory
iya.” without mechanism to increase
supplementa diameter of nares &
l oxygen. 2. Assess skin color for increase Oxygen intake.
dev’t of cyanosis.

3. Promote rest,
OBJECTIVE: -Lack of Oxygen will
minimize stimulation
-dyspnea result in cyanosis.
& energy expenditure.
-RR= -to decrease the
-rapid, equal *COLLABORATIVE: metabolic rate & Oxygen
chest 1. Monitor consumption.
expansion lab/diagnostic studies
as appropriate.

-Reveals & prevents any

further complications.
Assessme Nursing Nursing Nursing Rationale Outcome Actual
nt Diagnosis Goal Intervention Criteria Evaluation

SUBJECTIVE Ineffective After 24hrs *INDEPENDENT:

: thermoreg of thorough 1. Assess V/S (esp T) -Hypothermia After 24 hours Goal was
“Naa man to ulation r/t nursing predisposes infant to of close met, left
siya’y to intervention cold stress, utilization of monitoring, patient lying
hilanat prematurity , pt will nonrenewable brown fat infant was able on bed
gahapon, ny as exhibit stores. Hyperthermia to establish afebrile &
akaron wala evidenced thermal causes further normothermia with a
naman.”, as by poor homeostasis 2. Place infant in a respiratory depression and had T= temperature
pt. SO flexion & appropriate warmer, isolette, instead of increased RR, 36.5 C. appropriate
verbalized. lack of for age = incubator, or open bed leading to apnea & for age.
subcutaneo 36.5-37 C with radiant warmer or reduced O2 uptake.
us fat. (axillary) open crib wherein
OBJECTIVE: infant also has -Maintain thermoneutral
appropriate clothing. environment, helps
T=35 C prevent cold stress.

-tachypnea 3. Use heat lamps

during certain -Decreases heat loss to
procedures & warm the cooler environment
objects coming in of the room.
contact with the
infants body such as

1. Provide or -Helps prevent seizures
administer meds as associated with
prescribed. hyperthermia and
Assessm Nursing Nursing Nursing Rationale Outcome Actual
ent Diagnosis Goal Intervention Criteria Evaluation

SUBJECTIV Altered After 24hrs *INDEPENDENT: After 24hrs,

E: nutrition: of 1. Assess presence of -Determines the pt was seen
“Wala pa less than continuous reflexes associated appropriate feeding beside
na siya'y body nursing with feeding (i.e method for the infant. mother,
kaon ”, as requiremen intervention, swallowing, sucking & exhibiting
pt SO ts r/t to pt will coughing) good suck-
stated. small demonstrate and-swallow
stomach steady wt 2. Instill breast milk -Too rapid entry of reflex, and
capacity & gain in a or formula slowly over feeding into stomach showed to
OBJECTIVE prematurity normal 20min @ a rate of may cause rapid rebound have added
: as evidenced curve (@ 20ml/min. response with 10g.
by weak least 20- regurgitation, increased
-found feeding 30g/day) risk of aspiration & abd
patient reflexes & and also distension all of which
lying on NPO status. maintained compromises respi
bed supine growth. 3. Initiate intermittent status.
with IV D5 or tube feedings as
-small for indicted. -Gavage feedings may be
gestational necessary to provide
age adequate nutrition in
- wt= infant who has a poorly
coordinated suck-and-
swallow reflex or who
4. Position infant on becomes fatigued during
right side or prone oral feedings.
with HOB elevated @
30 degrees. -Facilitates gastric
emptying & prevents
1. Feed as frequently
as indicated based on
infant’s wight & -Infants <1250g are
estimated stomach usually fed q 2hrs;
capacity. infants b/w 1500 &