NURSING CARE PLAN

Name of Patient: ________________________________________ Age: _______ Civil Status: _________Sex: ___ ____Religion:
Address: ________________________________________Informant: ______________________ Relationship:
____________________________________________
Chief Complaint: _________________________________ Medical Diagnosis:
___________________________________________________________________
Date PROBLE ASSESSME NURSIN PLANNING IMPLEMENTATION
M LIST NT (cues & G (Objectives- long & EVALUATION
(According evidences/ DIAGNO short term) Rationale/ Justifications
to priority) Objective & SIS (Nursing Theories of Care,
Nursing Refer
Maslow’s subjective) Developmental stage, tasks,
Interventions ences
Hierarchy Principles, EBP, Standards of
of Needs Nursing Practice)

A Subjective: Ineffective After 20 minutes of - Maintain a - A neutral thermal https: Goal met.
P “ nakakaon Breathing nursing intervention neutral environment // After 20 minutes of
R ug hugaw pattern the neonate will: thermal minimizes the risk of www. nursing intervention
I gikan saako related to environme cold stress, which ncbi. the neonate was:
L maam” as Maternal - Be able to nlm.n
nt by increases metabolic
the mother genitourina demonstrate ih.go - able to
verbalized. ry tract
placing the demands for oxygen. v/
1 a normal demonstrat
infection neonate in The neonate is placed pmc/
4 respiratory e a normal
rate and
an in an incubator articl respiratory
breathing incubator designed to provide a es/ rate and
2 Objective:
0 Sternal pattern. or a radiant neutral thermal PMC breathing
2 retraction, - Be able to heat environment- 5139 pattern.
3 Tachypnea have clear warmer. temperature, air, 811/ - able to
or irregular breath radiating surface #:~:te have clear
respiration, sounds and temperatures, and xt=A breath
decreased diminished humidity are bnor sounds and
breath use of mal diminished
controlled to maintain
sounds or accessory %20h use of
the neonate’s eart
rales. muscle for accessory
temperature within a %20r
breathing muscle for
- Be able to normal range with ate breathing
have a minimal oxygen %20f - able to
capillary consumption required. indin have a
refill within gs capillary
a normal - Rub the - Gentle rubbing of the %20b refill
range. neonate’s neonate’s ankles, feet, y,in within a
feet and %20a normal
and back may
%201 range.
back or stimulate breathing 0%20
suction the after episodes of min
nose and apnea. When these %20p
the mouth measures fail, eriod)
and elevate suctioning of the nose .
the and mouth and raising
neonate’s the neonate’s head to a
head to semi-Fowler’s position
stimulate usually facilitates
breathing. breathing.

- Respiratory distress
- Administer syndrome can be
surfactant
largely prevented by
Name of Student Nurse & Signature: Year and Section: ____________Date/Duration of Patient Care:
Name of Clinical Instructor: Rating: _______________________ Remarks:
_______________________