ASSESSMENT NURSING GOAL PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Objective data: Ineffective To Monitor the vital sign Vital signs are To know the Breathing pattern
I observed the breathing maintain of the baby. checked as: condition of the improved after
baby having pattern related the Temperature: 98.6°F baby. some extent.
wheezing to pulmonary airway. Pulse:130 b/min.
sound. and Respiration: 40 b/min.
neuromuscular
immaturity,
decreased Position for optimal air Proper position are To remove the
energy and exchange. given i.e side lying secretions from
fatique. position given to the mouth.
baby.

Observe the signs of Observed the patient To prevent from

respiratory distress. condition. Respiratory further
rate should be complication.
monitored and
observe the baby skin
colour.

Proper suctioning done Suctioning done To remove the

only as based on properly every 2 hrly. secretions from
assessment. mouth.

Objective data: Ineffective To Assess the general The general condition To know the Thermoregulation
I observed the thermoregulatio maintain condition. of the baby is assessed condition of the improved after
baby n related to the body i.e skin colour. baby. some extent.
temperature are immature temperat
increase. temperature ure. Monitor vital signs Vital signs are To know the
control and frequently. checked as: health status.
ASSESSMENT NURSING GOAL PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
decreased Temperature: 38°F To prevent from
subcutaneous Pulse:138 b/min. the infection.
fat. Respiration: 40 b/min.

Provide warm and clean Warm &clean clothes To prevent from

clothes. are provided. infection.

Keep the baby in the , Kept the baby in the To provide warn
radiant warmer. radiant warmer. the baby.
Objective data: Imbalance To Assess the nutritional Assessed the health To know the Nutritional status
I observed the nutrition status maintain status of the baby. status. condition of the improved upto
baby having less than body the baby. some extent.
lethargy and requirement nutritiona
weakness. related to l status. Monitor the weight of Weight are checked of To know the
inability to the baby. the baby.( 1.10 kg). health status of
ingest nutrients. the baby.

Provide adequate Calories are given to To maintain the

calorie intake (80-120 the baby 80 nutritional level.
kcal/kg/24 hours). kcal/kg/24 hours.

Administer intravenous Intravenous fluid is To maintain the

fluid as prescribe by the administered to the fluid and
doctor. baby i.e 40 ml electrolyte
ASSESSMENT NURSING GOAL PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
dextrose given to the balance.
baby.

Assist mother with Assisted mother in the To provide

expressing breast milk in expressing the proper breast
to establish and breast milk by breast feeding.
maintain until infant pump.
can breast feed.

Objective data: Knowledge To Assess the knowledge Knowledge level is To help know Knowledge
I observed the deficit to the improve level of child’s parents. assessed. the improved upto
parents look mother related the Information. some extent.
anxious & to baby knowledg
asked many condition. e level. Maintain the Understandable It helps to easily
doubts. understandable language is used i.e understand.
language with the Punjabi or Hindi.
parents.

Clarify the all doubts Cleared all the doubts To Improve the
and make good IPR by answering the knowledge
with the parents. questions. level.

Educate the parents Educate the parents To improve the

regarding the about treatment and knowledge
importance of treatment follow up care level.
and its side effects.