SILLIMAN UNIVERSITY

DUMAGUETE CITY

NURSING CARE PLAN

 CUES/EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective:
• Mother verbalized Risk for infection r/t Within my care, the infant • Monitor vital signs • To keep track of At the end of our care all
“wala pa man na presence of newly clamped will remain free of baseline data objectives were met as
gilimpyohan iya cord stump infection as evidenced by: • Observe Principles • To help prevent evidenced by:
pusod” of asepsis spread of
•Cord Stump is free pathogenic • Mother verbalized
Objective: from bleeding substances “wala naman
• Date and time of •Umbilical cord is • Inspect the infant’s • If the clamp gadugo iya pusod”
delivery: Sept 14, healing and free of cord to be certain it loosens before • Absent of blood on
2006, 5:35 pm infection is clamped securely thrombosis, binder
• Delivered via •Area around the hemorrhage will • Umbilical stump
NSVD cord stump is dry result appeared dry and is
• Apgar’s score is 9 and is without • Assess cord for • The cut surface of healing well
at the 1st minute purulent discharges number of vessels the umbilical cord • Absence of foul
and 9, after 4 •Absence of foul without touching presents a site for odor
minutes odor the cut surface. proliferation of • Gauze remained
• Assessed cord •Gauze remains dry microorganisms dry and free from
stump and noticed •Vital signs remain • Perform Cord Care, • To promote healing secretions
blood on binder within normal range fold diapers down of the cord stump • Vital signs within
present T = 36.5 – 37.2 °C to expose the cord and prevent normal range
• Cord care hasn’t P = 120 – 140 bpm infection, Keeping T = 37 °C
been performed R = 30 – 60 cpm the cord exposed P = 125 bpm
• No foul odor noted facilitates drying R = 35 cpm
• Gauze soaked with and inhibits
secretions bacterial growth
• Skin is pinkish in • Observe neonate • Early detection of
color for signs and signs of infection
• Vital signs symptoms of can provide prompt
T = 37 °C infection. Assess intervention
P = 120 bpm, cord for erythema,
R = 40 cpm, bleeding, foul odor
regular, rapid and purulent
respirations discharge

• Perform Infant • To cleanse the

Sponge Bath body of
microorganisms
this would provide
comfort to the baby
and prevent
 SILLIMAN UNIVERSITY
DUMAGUETE CITY

NURSING CARE PLAN

 CUES/EVIDENCES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
CUES/EVIDENCES NURSING DIAGNOSIS
NURSING DX OBJECTIVES
SILLIMANINTERVENTIONS
UNIVERSITY RATIONALE EVALUATION

Objective: DUMAGUETE CITY

Subjective:
• Mother
Date and Altered
Risk forNutrition:
ineffective
Less Within my care, NURSING
the baby
infant •CARE PLAN
Monitor Vital signs • To keep track of At the end of my
our care, a;;
all
verbalized
time of delivery: thanthermoregulation
body requirements will maintain
increase its
a stable
bodilybody baseline data objectives were met as
“Maglisod
Sept 14, 2006, ko og5:35 Related
related to mother’s
immature requirementsasasevidenced
temperature evidenced • Mummifying
Educate mother theon evidenced by:
patutoy niya,
pm inability
thermoregulation
to producecenter
milk by: the importance
baby properly of • To keep the
Mother’s gained
baby
•gamay ra gyud
Delivered and sudden changes in breastfeeding knowledge
warm and provide
on • Vital signs
Mother verbalized
within
sukad
via NSVD gabi-i” environmental • •Vital
MotherSigns
expresses
within breastfeeding will
comfort “naa naman
normal rangegatas
• “Murag
Apgar’s temperature. normal
understanding
range of • Encourage the • motivate
To form aher to
good mugawas
T = 36.5 °Cnya
iyang is
score iluwa
9 at akong
the 1st Tbreastfeeding
= 36.5 – 37.2 °C mother to be with continue
bonding makatotoy
P = 120 bpm na sya
totoy” and 9, after
minute Ptechniques
= 120 – 140 and
bpm • the
teach
child
the as
mother
often in
as breastfeedingwhile
relationship og=tarong
R 45 cpmog
4• minutes “Maluoy Rpractices
= 30 – 60 cpm proper
possible • To ensure
keeping theproper
baby nakalibang na pod
•
man gud ko sa ako
Mother and • Newborn will be breastfeeding nutrition of neonate
warm • sya”
Newborn appeared
bata…”
infant are staying •Mother
calm andexhibits
rested • Make
techniques
sure • Bathing quickly in • Mother
relax andappeared
rested
in the alley not • continued
Baby being • environment
Monitor neonate is a warm • relax andisatnegative
Neonate ease
Objective:
therapeutic for the breastfeeding
properly draped for signs
warm enough
of for • To establish need
environment avoids while breastfeeding
for chilling or
• careDate of andantime
infantof during when dehydration
bathing. Wash andand for immediate
heat loss from • Infant displayed
excessive sweating
•delivery: Sept 14,
Sudden •Assume
performing dry head
mucous firs, then medical
evaporation and • good
Newborn is reflex
sucking
2006,
shift from pm
5:35 responsibility
procedures (ex.
for membranes
expose and wash intervention
convection while breastfeeding
properly draped
• intrauterine
Delivered via effective
infant sponge bath) one area of the • Infant doing
when voided twice
NSVD
environment to the • breastfeeding
Newborn is • body at a time
Encourage and
mother and defecated with
procedures
• environment
Apgar’s score is 9 properly clothed dry thoroughly
to breastfeed baby • Stimulation for • soft greenish
Newborn is stool
outside
at the 1stofminutethe •Neonate
and kept will
warm void
and before
every 2° moving to production of milk • Mucous clothed
properly
mother’s
and 9, after womb4 ordry
defecate within another area membranes
and kept warm and
•minutesEnvironmen normal output appeared wet
dry
t• is hot and
Verbalnot well • Avoid unnecessary • Exposure of body
ventilated
reports of exposure of body parts may cause the
•unsatisfactory
Presence of parts when baby to chill
breast – feeding
sweating in the performing
knowledge
head procedures
• Mother
shows difficulty
wrapping the infantin • Avoid placing • Placing the infant
latching-on
in thick blanketsthe infant on cool on a cool surface or
baby if it is too hot
even surfaces or using using a cool
• Vital• signs Neonate cold instruments in instrument
shows
T = 37 inability
°C to assessment (ex. increases heat loss
nurse
P = 120well,
bpm, doespulse stethoscope) by conduction
notirregular
is demonstrate
effective
R = 40 cpm,suck and • Place infant away • Heat may be lost
swallowrapid
regular, reflex from windows, directly from the
avoid drafts infant’s body to