NURSING

ASSESSMENT INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Objective: Ineffective airway An ineffective After 10 mins of Assess and monitor To assess level of After 10 mins of
- newborn clearance related breathing pattern nursing breathing pattern of respiratory distress nursing intervention,
- DOB 11/15/2020 to patient’s is defined as the intervention, the the patient. the patient was able
- Full-term, NDS inability to inability to clear patient will be to cry loudly, and no
- 38 weeks AOG remove airway secretions or able to cry Clamp and cut cord To initiate nose flaring was
- weak cry secretions as obstructions from loudly, and no immediately and resuscitation observed.
- mild nose flaring manifested by a the respiratory nose flaring will prepare transfer of protocol
- secretions coming weak cry upon tract to maintain be observed. patient for suctioning (Goal completely
out from the nose delivery and mild a clear airway met)
and mouth nose flaring Inform mother that
- RR is 40 br/min the baby needs To educate mother
- acrocyanosis – assistance in of the procedures to
bluish discoloration breathing and that care for the baby
of hands and feet suctioning will be
- APGAR Score 6 required

Proceed with routine To remove blocks of

suctioning secretion in the
mouth and nose
immediately
relieving the patient
from respiratory
distress
Rechecked and
monitor the patient’s To ensure stability
respiration rate and management of
patient’s respiration
Document the
procedure To provide a
appropriately on the comprehensive
birthing room record nursing care
or in the progress
notes.