NURSING CARE PLAN

Name of Patient: S, baby girl Attending Physician: Dr. U

Age: 2 days old Ward/Bed umber: OBSW / #9 Impression/Diagnosis: LFT female neonate AGA in cephalic via NSVD
Nursing
Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Rationale Evaluation
Interventions
Date and Time: Risk for Infection At increased risk After 4 hours of Stressed proper A first-line Goals Met.
July 29, 2016 related to for being invaded nursing hand hygiene by defense against
4:00 PM inadequate acquired by pathogenic interventions, the all caregivers healthcare- Date and Time:
immunity organisms. patient must have between associated July 29, 2016
remained herself therapies/clients infections (HAI) 8:00 PM
Because newborns free from infection
Objective: have difficulty for the duration of Monitored vital Provides
Patient is 2- forming antibodies hospital stay signs every baseline data After 4 hours of
day old infant against invading hour and allows nursing
antigens until quick interventions, the
about 2 month of identification patient remained
age, newborns are of any herself free from
prone to infection. deviations that infection for the
This inability to could indicate duration of hospital
form antibodies is infection stay
the reason that
most Monitored clients To limit
immunizations visitors/caregivers exposures, thus
against childhood especially those reduce cross-
diseases are not who are sick contamination
given to infants
younger than 2 Provided health To limit
months of age. teachings about exposures, thus
infection control reduce cross-
contamination
 NURSING CARE PLAN
Name of Patient: S, baby girl Attending Physician: Dr. U

Age: 2 days old Ward/Bed umber: OBSW / #9 Impression/Diagnosis: LFT female neonate AGA in cephalic via NSVD

REFERENCES:

Nurses Pocket Guide

11th Edition
Marilyn E. Doenges
Mary Frances
Moorhouse
Alice C. Murr

Maternal and Child

Health Nursing:
Care of the
Childbearing &
Childbearing Family
5th Edition
Adele Pillitteri

Clustered cues Nursing Diagnosis Rationale Outcome Criteria Nursing Interventions Rationale Evaluation
 NURSING CARE PLAN
Name of Patient: S, baby girl Attending Physician: Dr. U

Age: 2 days old Ward/Bed umber: OBSW / #9 Impression/Diagnosis: LFT female neonate AGA in cephalic via NSVD

Date and Time: Risk for Falls At risk for After 4 hours of Inform significant To provide Goals Met.
July 29, 2016 related to increased nursing intervention others to use information
4:00 PM unattended susceptibility the mother must safety precautions about the Date and Time:
newborn in bed to falling that have verbalized to avoid future specific items to July 29, 2016
Objective: may cause knowledge of injuries use in order to 8:00 PM
Unattended physical harm. adequate means for provide safety to
newborn in bed safety of the the newborn After 4 hours of
Lack of pillows newborn and to nursing
surrounding the apply the health Instruct the To the avoid intervention, the
infant teachings regarding mother to put infant to roll mother verbalized
Absence of side the problem pillows beside the over the edge of the understanding
rails on bed identified by the baby the bed of the teaching
student nurse. and applied the
REFERENCES: Educated the safety precautions
To provide
mother not to as evidence by:
information
Nurses Pocket leave the newborn
about the safety
Guide without any Te sige day
of newborn
13th Edition attendant ah. Salamat gid
Marilyn E. sa pagtudlo as
Doenges verbalized by
Mary Frances the mother.
Moorhouse Pillows were
Alice C. Murr placed around
the neonate.
 NURSING CARE PLAN
Name of Patient: S, baby girl Attending Physician: Dr. U

Age: 2 days old Ward/Bed umber: OBSW / #9 Impression/Diagnosis: LFT female neonate AGA in cephalic via NSVD