ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: STG: Indipendent: Goal met: “alam ko na po kung

“Mapula yung paligid ng pusod
Risk for infection r/t insufficient After one hour of intervention, 1. Note risk factors for paano ang tamang pag cord care
nya tapos mukang may sugat.
knowledge to avoid exposure to the mother will learn how to give occurrence of infection. sa baby ko” as verbalized by the
Panay lang sya iyak kahit kapag
pathogens AEB exposed proper cord care by: 2. Assess and document skin mother.
hinahawakan” as verbalized by
umbilical cord conditions around the base of
the mother
1. Giving the proper and the umbilical cord.
hygienic method of cleaning 3. Note signs and symptoms of
Objective:
the remaining umbilical cord. fever.
T= 37
4. Orient the mother abut the
PR=163
proper way of cleaning the
RR= 45
umbilical cord.
W= 4.6 kg
LTG: Dependent: Goal met: AEB the mother
Crying
After one day of nursing 1. Instruct the mother how to demonstrated proper cord care
intervention, the mother will be protect the integrity of the
able to give proper cord care for skin and prevent spread of
the baby. infection around the base of
the umbilical cord.
2. Teach and demonstrate how
to do proper cord care.
 ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION EVALUATION
Subjective: Risk for infection r/t decreased Delaying the clamping of the Indipendent: Due to the delayed cord
“perform properly timed cord in hemoglobin and
umbilical cord after birth by 1. Observed for 1-3 minutes clamping, the neonate has
clamping” as verbalized by the diminished oxygen-
several minutes or after the after childbirth before benefited such as improved
doctor carrying capacity of the
pulsation stops. cutting. This is done to transitional circulation, better
blood
allow the transfusion of establishment of red blood cell
additional blood from the volume, decreased need for
placenta to the baby. This blood transfusion, and lower
will then result in an incidence of necrotizing
increase in the baby’s enterocolitis and intraventricular
iron reserve. hemorrhage.
2. Examine the umbilical
cord structure.
3. Asses the signs of cord
healing and signs of
infection.
Dependent:
1. Ask the doctor if there is
any abnormality on the
umbilical cord.