Cabuya, Lorrea Alexandra S.
BSN - IIA
1 Assessment 2 Diagnosis
Subjective Data:
"mabigat nga ang
paghinga niya" as stated
by the client's SO.
Objective Data
Dyspnea (RR - 67bpm)
Poor oxygen saturation
Shallow breathing
Nasal flaring
Meconium did not come
out 24-48 hours
Neonates vomit green
Imperforate Anus
3 Planning 4 Intervention 5 Evaluation
Ineffective Breathing After an 2-3 hour the Establish rapport with Goal partially met.
Pattern related to patient will manifest the patient and SO After 2-3 hour of
Rationale: To gain trust and
abdominal distention effective breathing nursing intervention
encourage cooperation.
and rigidity pattern with normal the infant ventilation
respiratory rate, Assess respiratory improved as
depth, and oxygen status noting signs of evidenced by:
saturation respiratory distress Infant's skin is pinkish in
(tachypnea, dyspnea, color.
grunting retractions) RR of 76bpm
Rationale: Tachypnea
indicates respiratory
distress esp when RR is
>75cpm after the first hour
of life. Expiratory grunting
represents evidenced by
attempt to maintain alveolar
expansion. In color nasal
flaring is a compensatory
mechanism to increase
diameter of CRAP nares &
increase oxygen intake.
Assess skin color for
development of
cyanosis
Rationale: Lack of
oxygenation will result to
cyanosis
Promote rest and
minimize stimulation &
energy expenditure
Rationale: To decrease
metabolic rate and oxygen
consumption.
Cabuya, Lorrea Alexandra S.
BSN - IIA
1 Assessment 2 Diagnosis
Subjective Data:
"mainit yung parte kung
saan siya inoperahan,
atsaka mayroong sugar
at namamaga rin" 'hindi
ko rin naman alam kung
anong gagawin ko" as
verbalized by the SO
Objective Data:
Affected area hot,
tender to touch.
Skin and tissue color
changes (red, purplish,
black)
Swelling around the
initial injury
High pitched cry
Presence of moist and
lesion in the area
Imperforate Anus
3 Planning
Impaired Skin
Integrity related to
colostomy as
evidenced by:
There is stitching drain.
The existence of the
incision.
The presence of skin
irritation.
There is swelling and
redness.
The skin around the
colostomy wet and no
drainage.
4 Intervention 5 Evaluation
After an 8 hour shift Establish rapport with The goal is met.
the patient's skin the patient and SO The SO understands
Rationale: To gain trust and
around the stoma how to do proper
encourage cooperation.
are will be pink in wound care.
appearance, and Keep Sterile dressing The patient's skin is
free from skin technique around dry and free from
damage, incision free wound care skin damage after
Rationale: A sterile
of redness, no technique reduces the risk
the 8 hour shift, the
swelling and of infection in impaired incision site is free
drainage. tissue integrity. This involves from redness,
the use of a sterile absence of swelling
procedure field, sterile
and drainage.
gloves, sterile supplies and
dressing, sterile instruments.
Check every two (2)
hours for proper
placement of casts and
assess skin tissue
integrity
Rationale: Mechanical damage
to skin and tissues (pressure,
friction, or shear) is often
associated with external
devices.
Instruct patient,
significant others, and
family in the proper care
of the wound, including
handwashing, wound
cleansing, dressing
changes, and application
of topical medications).
Rationale: Accurate
information increases the
patient’s ability to manage
therapy independently and
reduces the risk for infection.
Cabuya, Lorrea Alexandra S.
BSN - IIA
1 Assessment 2 Diagnosis
Subjective Data:
"pangalawang gabi na
nga siyang nagsusuka at
nilalagnat, hindi rin
gaanong umiinom ng
tubig" "nangangalumata
na nga siya lubog na din
ang pisngi" as verbalized
by the SO
Objective Data:
Fever (38.7C)
Vomiting
Sunken Fontanels
Sunken eyes
Weak pulse
Decreased skin turgor
Poor capillary refill
Cyanotic
Imperforate Anus
3 Planning 4 Intervention 5 Evaluation
Deficient Fluid After an 3-4 hours Establish rapport with The goal is met.
Volume related to the patient's fever the patient and SO The SO understands
Rationale: To gain trust and
nausea, vomiting, will be gone, as well and learns how to
encourage cooperation.
fever or diaphoresis as the vomiting. The monitor I&O, also the
patient will manifest Provide a comfortable causes of
stable vital signs and environment by dehydration.
have balanced input covering the patient The patient
and output. with light sheets. manifests normal
Rationale: Drop situations
where patients can vital signs and the
experience overheating to patient is free from
prevent further fluid loss. fever and vomiting.
Educate SO about
possible causes and
effects of fluid loss or
decreased fluid intake.
Rationale: Enough knowledge
aids the family in taking part in
the plan of care.
Teach family members
how to monitor output in
the home. Instruct them
to monitor both intake
and output.
Rationale: An accurate
measure of fluid intake and
output is an important
indicator of a patient’s fluid
status.
Administer intravenous
hydration if needed.
Rationale: Severely
dehydrated patients or
patients unable to take oral
hydration may require IV
hydration to maintain
appropriate hydration level.