Cues Background

KnowIedge
Nurs|ng
D|ognos|s
F|onn|ng
Objective
Cues
Rate of
respirations are
sometimes
irregular
Jaundice
Premature
newborns is at
increased risk
for being
invaded by
pathogenic
organisms due
to deficient
immunologic
defenses which
can be life-
threatening and
harmful to brain
development
with lifelong
effects.
Whaley and Wongs '
"Essentials of Pediatric
Nursing
Risk for
nfection related
to deficient
immunologic
defenses.
After eight hours
of Nursing
nterventions
the patient must
be protected
from infection
ursing Intervention RationaIe EvaIuation
. Stress proper hand
hygiene by all
caregivers between
therapies/clients.
2. Monitor client's
visitors or caregivers
for respiratory
illnesses, offer masks
and tissues to client or
visitors who are
coughing or sneezing.
3. Administer or monitor
medication regimen.
. A first line
defense against
health care
associated
infections (HA)
2. To limit
exposures, thus
reduce cross
contamination.
3. To determine
effectiveness of
therapy or
presence of side
effects.
After nursing
interventions the
patient exhibit no
evidence of infection.
as manifested by:
Normal Body
Temperature
Normal Heart rate
Regular Respirations
ues 8ockground
Know|edge
Nurs|ng
D|ognos|s
F|onn|ng
bjective cues:
-Very small and
appear scrawny
-Ear cartilage is
soft and pliable
-have prominent
labia minora
and clitoris.
Reflex activity is
only partially
developed
Premature
newborns are at
risk for growth
above the 97
th
percentile or
below the 3
rd
percentile for
age, crossing
two percentile
channels.
Risk for
disproportionate
growth related
to prematurity
After eight
hours of nursing
interventions the
patient must be
monitored and
receive
appropriate
nutrition as
indicated
ursing Intervention RationaIe EvaIuation
. Perform nutritional
assessment
2. Monitor growth
periodically
. verfeeding or
malnutrition (protein
and other basic
nutrients) on a
constant basis
prevents child from
reaching healthy
growth potential, even
if no disorder or
disease exists.)
2. Aids in evaluating
effectiveness of
interventions and
promotes early
identification of needs
for additional actions.
After nursing
interventions the
patient received
appropriate nutrition as
indicated.
ursing
Intervention
RationaIe EvaIuation
3. nvestigate
deviations from
normal ( e.g. height,
weight, head
circumference, etc.
Deviations can be
multifactorial and
require varying
interventions