Name: Aileen Reign Malonzo Performance Task # 9

BSN 2-Y1-4

Make an NCP, one actual and one potential from the nursing diagnoses given for high-risk infants:
1. Ineffective airway clearance related to presence of mucus or amniotic fluid in airway.
2. Ineffective thermoregulation related to newborn status and stress from birth weight variation.
3. Risk for infection related to lowered immune response in newborn.
4.Risk for imbalanced nutrition, less than body requirements related to lack of energy for sucking.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
 Assess the client's Ineffective airway Goal: The goal of nursing Position the client upright Positioning the client Short-term: After 24 hours
airway, breathing, clearance related to care is to maintain a patent to promote lung expansion. upright promotes lung of nursing intervention, the
and circulation presence of mucus or airway and promote expansion and secretion client maintain clear, open
(ABCs) amniotic fluid in airway effective clearance of drainage. airways as evidenced by
 Assess for abnormal mucus or amniotic fluid. the absence of abnormal
breath sounds breath sounds, a
 Assess for abnormal Short-term: After 24 hours Deep breathing and respiratory rate within the
respiratory rate, of nursing intervention, the Encourage the client to coughing aid in the normal range (12 to 20
rhythm and depth client will maintain clear, deep breathes and cough loosening and expulsion of breaths per minute), a
 Assess the client's open airways as evidenced effectively. secretions from the regular and adequate depth
oxygen saturation by the absence of abnormal airways. of respiration, and the
levels. breath sounds, a ability to effectively cough
respiratory rate within the up secretions after
 Assess the client's
normal range (12 to 20 If the client is unable to treatments and deep
hydration status.
breaths per minute), a cough adequately, breaths.
 Assess for dyspnea regular and adequate depth Assist the client with suctioning may be required
 Assess for excessive of respiration, and the suctioning, as needed. to clear secretions from the Long-term: Within the next
secretions ability to effectively cough airways. two weeks, the client is
 Assess for up secretions after able to identify and avoid
Hypoxemia/cyanosis treatments and deep specific factors that
 Assess for inability breaths. To enhance oxygenation interfere with effective
to remove airway and lessen respiratory airway clearance, such as
secretions Long-term: Within the next Administer bronchodilators distress, bronchodilators smoking, exposure to
 Assess ineffective or two weeks, the client will and supplemental oxygen, and supplementary oxygen environmental pollutants,
absent cough identify and avoid specific as prescribed. may be required. and engaging in activities
 Assess for orthopnea factors that interfere with that aggravate respiratory
 Assess for any risk effective airway clearance, symptoms, as evidenced by
factors for such as smoking, exposure Humidified air aids in the a written plan of avoidance
ineffective airway to environmental Provide humidified air to loosening of secretions and strategies and verbal
clearance, such as pollutants, and engaging in help loosen secretions. making them easier to commitment during
pregnancy, upper activities that aggravate cough up. discharge planning
respiratory infection, respiratory symptoms, as sessions.
and chronic evidenced by a written
obstructive plan of avoidance Maintain adequate Keeping hydrated helps to
pulmonary disease strategies and verbal hydration. thin secretions and make
(COPD). commitment during them simpler to
discharge planning expectorate.
 sessions.
Educating the client and
Educate the client and
caregiver about the signs
caregiver on signs and
and symptoms of poor
symptoms of ineffective
airway clearance and how
airway clearance and how
to prevent it can aid in the
to prevent it.
early detection and
resolution of difficulties.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

 Assess the Ineffective Goal: The goal of nursing 1.Control the temperature 1. These techniques allow Short-term:
newborn’s thermoregulation related to care is to maintain the of the environment or for a more gradual After 24 hours of nursing
temperature rectally newborn status and stress newborn's temperature move the patient to a warming of the body. intervention, the client
 Assess the from birth weight variation within the normal range warmer location. Maintain Ventricular fibrillation can shows no evidence of cold-
newborn’s skin (36.5-37.5 degrees the patient's and linens' be caused by rapid heat. stress and gradual
color, temperature, Celsius). dryness. Moisture enhances heat stabilization of body
and turgor loss through evaporation. temperature within an
 Observe the Short-term: acceptable weight range.
newborn’s behavior After 24 hours of nursing 2. Body temperature
for signs of intervention, the client will 2. Adjust the heat source should only be elevated a
hypothermia or show no evidence of cold- based on the patient's few degrees every hour. Long-term:
hyperthermia. stress and gradual physical response. Vasodilation happens when After 2-3 days of nursing
 Assess the stabilization of body the patient's core intervention, out of the
newborn's temperature within an temperature rises, resulting isolette, the client keeps his
environment for acceptable weight range. in a drop in blood pressure. or her body temperature
temperature and Complications of within safe limits.
humidity. rewarming include
 Identify any risk Long-term: hypotension, metabolic
factors for After 2-3 days of nursing acidosis, and dysrhythmias.
ineffective intervention, out of the
thermoregulation, isolette, the client will keep 3. Extra covering (passive 3. Warm blankets are a
such as prematurity, his or her body temperature warming), such as clothing passive way of rewarming.
low birth weight, within safe limits. and blankets, should be
and infection. provided; postoperative
patients should be covered
with heat-retaining
blankets.
 4. Give alert patients hot 4. A heat source is
oral fluids. produced by warm fluids.

5. Extra heat sources 5. These measures increase

include: a heat lamp, a core temperature and
radiant warmer, warm circulation. When the body
pads, mattresses, or temperature falls below 30
blankets, soaking in a °C (86 °F), core warming
warm bath, heated, occurs.
moisturized oxygen, and
warmed intravenous fluids
or lavage fluids.

6. Avoid manually rubbing, 6. Rubbing might cause

washing, or massaging additional damage to
frostbitten regions. frozen tissue.

7. Explain to the patient 7. To avoid confusion,

and SO all procedures and repeated explanations are
treatments. required.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

 Examine the Short-term: After 3 days of Encourage all caregivers Hand cleanliness is the Short-term: After 3 days of
newborn's vital Risk for infection related to nursing intervention the and visitors to practice most important way to nursing intervention the
signs for infection lowered immune response client will remain free of good hand hygiene. avoid infection spread. client remains free of
symptoms such as in newborn. infection, as evidenced by infection, as evidenced by
fever, tachycardia, normal vital signs and the Keep the newborn in a A clean and sterile normal vital signs and the
and tachypnea. absence of signs and clean and sterile atmosphere helps to limit absence of signs and
symptoms of infection. environment. the chance of hazardous symptoms of infection.
 Examine the skin of microorganisms coming
the infant for Long term: After 7 days of into touch with the Long term: After 7 days of
symptoms of nursing intervention the newborn. nursing intervention the
infection, such as client will demonstrate a client demonstrates a
redness, edema, and meticulous hand-washing meticulous hand-washing
discharge. technique Avoid intrusive procedures technique
and operations that aren't Invasive procedures and
absolutely necessary. unnecessary procedures
 Examine the
mucous membranes can raise the risk of
of the infant for infection.
symptoms of
infection, such as
redness, swelling,
and discharge. Vaccinations should be Immunizations protect the
administered on time. newborn against common
 Look for indicators infectious illnesses.
of infection in the
newborn's behavior,
such as lethargy,
irritability, and poor Nutrition, hydration, and Supportive care aids in the
eating. rest are examples of development of the
supportive care. newborn's immune system
 Determine any and ability to fight
infection risk infection.
factors, such as
prematurity, low
birth weight, and
maternal infection.
Keep a close eye on the
newborn for any signs of It is critical to closely
infection. monitor the baby for any
signs of infection in order
to diagnose and treat it as
soon as possible.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

 Determine the Risk for Imbalanced Short-term: After 1 week Correctly position the Proper posture can aid in Short-term: After 1 week
weight and height Nutrition, Less Than Body of nursing intervention, the newborn for feeding. the development of the of nursing intervention, the
of the infant. Requirements Related to patient will maintain newborn's ability to suck patient maintains normal
Lack of Energy for normal weight gain. and swallow. weight gain.
 Determine the Sucking
newborn's daily Long-term: After 1 month Long-term: After 1 month
calorie and of nursing intervention, the of nursing intervention, the
nutritional needs. newborn will develop Feed the newborn on a newborn developed a
 normal eating and sucking regular basis. Frequent feedings aid in normal eating and sucking
 Examine the patterns. ensuring that the newborn patterns.
newborn's feeding receives adequate calories
habits and intake. and nutrients.

 Look for indicators Allow the newborn to feed Allowing the newborn to
of malnutrition in themselves at their own time their feedings reduces
the infant, such as speed. overfeeding and
low weight gain, regurgitation.
dry skin, and brittle
hair. If the newborn is not
As needed, supplement getting enough calories and
 Determine any risk feedings with breast milk nutrients from breast milk
factors for or formula. or formula alone,
nutritional supplementing feedings
imbalance, may be necessary.
including as
prematurity, low Calorie- and nutrient-dense
birth weight, and Make calorie- and nutrient- foods and fluids aid in
cleft lip or palate. dense foods and fluids ensuring that the infant
available. receives the nutrition
required for growth and
development.

Close monitoring of the

Keep a close eye on the newborn's weight and
newborn's weight and intake is critical for early
intake. discovery and correction of
nutritional imbalances.

Educating parents and

Educate parents and caregivers on how to
caregivers on the promote healthy food and
importance of healthy food nutrition can assist to
and nutrition. prevent nutritional
imbalances in the long run.