XXXXXXXXXXXX Performance Task #9

BSN 2-YA-9

Make an NCP, one actual and one potential from the nursing diagnoses given for high-risk infants:

Actual: Ineffective thermoregulation related to new born status and stress from birth weight variation.

Potential: Risk for imbalanced nutrition, less than body require- ments related to lack of energy for sucking.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Objective Ineffective to monitor new -Check the -Regular After the nursing intervention
Data: thermoregul born closely to temperature temperature the objective was met and the
ation related maintain with a rectal monitoring will patient's temperature was
-New born to new born temperature temperature determine reached within normal range
temperature status and and prevent check first, then adequate or and normal weight.
was 97.2F. stress from hyperthermia check the insufficient Partially Achieved
-Skin was birth weight and cold stress temperature of thermoregulation.
cool to variation. the axilla or use
touch. Goal: a thermostat
-There was with an open
very little -The new born base and the
clothing on will maintain a spreader is
the new body warm.
born. temperature of
-New born 97.7F-99.5 F by -Put the baby in -Warming the new
was not on discharge. an incubator or born and
the heat in a warm state. adequately
lamp. -The new born maintaining the
-New born will maintain a range of acceptable
was not normal weight. heat.
wearing a“
beanie” hat. -The new born -Monitor the -maintain the
-Lack of will display no temperature normal
subcutaneou signs and control system, temperature of the
s fat. symptoms of the spreader is new born child's
Ineffective cold stress such warm (maintain body and reduce
thermoregul as axillary the upper limit the possibility of
ation temperature of 98.6 ° F, heat loss through
below, poor depending on conduction,
feeding, or cool the size and age convection,
to touch by of the baby) radiation and
discharge. Estimate urine evaporation.
output and
specific gravity.

-Monitor weight -Quick drying and

gain step by laying on a warm,
step. If the dry surface
weight gain is prevents heat loss
not sufficient, through
increase the evaporation.
ambient
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 temperature as
indicated.

-Note the
development of
tachycardia,
flushing,
diaphoresis,
lethargy,
apnoea or
seizure activity.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

S
Objective Data: Risk for PLAN/GOAL - Assess -Assess infant EXPECTED OUTCOME;
imbalanced mother's sucking and After the nursing intervention
-Unsatisfactory nutrition, less After the knowledge swallowing ability. the mother is already
breastfeeding than body nursing about To control the demonstrating proper
process. require- interventions, breastfeeding. effectiveness of breastfeeding techniques.
ments The mother food The mother already
-Insufficient related to will understands the causes that
emptying of lack of demonstrate -Weight the -To achieve an cause the babies' energy to
each breast per energy for techniques to patient. effective weight. suck.
feeding sucking. enhance Perform at The same satisfactory
breast feeding regular -To facilitate the breastfeeding regimen was
-Observable experience. intervals and connection achieved with the baby content
signs of document the between the after feeding and gaining weight
inadequate The mother results patient and the accordingly.
infant intake will mother.
understand
the causative -Monitor daily
contributing -Administer the caloric and fluid
factors of prescribed intake.
infants lack of food for or
energy in gastric feeding
sucking. as directed by
the physician.
Achieve -Record the daily
mutually -Encourage the weight of the infant
satisfactory mother to to Improving weight
breast feeding breastfeed as and nutrition in the
regimen with needed. body.
infant content
after feeding -Teach the
and gaining mother the
weight proper position
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 appropriately while
breastfeeding
and educate
the mother on
how to
massage her
breasts and
nipples before
nursing the
infant.

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