NURSING CARE PLAN

PATIENTS BACKGROUND

Name: Baby Boy Rojas

Address: Ginitligan, Baras, Catanduanes
Age:1 hour
Birthday: September 21, 2016
Civil Status: None
Sex: Male
Religion: Catholic
Nationality: Filipino
Chief Complaint: Meconium Stained
Tentative Diagnosis: Live Term Baby Boy Delivered via NSD; Cephalic; BW 3.2kg; AS 8/10; Meconium Stained
Final Diagnosis: Live Term Baby Boy Delivered via NSD; Cephalic; BW 3.2kg; AS 8/10; Meconium Stained
Date Admitted: 09/21/16; 9:38 AM
Attending Physician: Ma. Consuelo I. Barceta, M.D

PAST HEALTH HISTORY: No history of medical illness

PRESENT HEALTH HISTORY: BW 3.2kg; Delivered via NSD; Meconium Stained

 SCIENTIFIC
EVALUATION/
NURSING INFERENCE OF NURSING NURSING
CUES RATIONALE EXPECTED
DIAGNOSIS THE NURSING OBJECTIVE INTERVENTION
OUTCOMES
DIAGNONSIS
Vital Ineffective Aspiration of Within our Assess and report Further signs and At the end of our care,
signs: breathing meconium results in care, the further sings of symptoms could the newborn achieved
pattern r/t respiratory distress newborn will respiratory distress lead to effective breathing
T aspiration of that, in severe cases, have an complications pattern as evidenced
36.1C meconium can be life effective which may result by;
P 120 during birth Threatening. There breathing to chronic
bpm is strong suggestive pattern as hypoxia and
R 68 evidence that evidenced by; acidosis,
prevention of increasing the
meconium risk of CNS
aspiration, damage
by its removal from
the respiratory tract, Absence of Clear the newborns This helps RR= 58 cpm fast and
can ameliorate or respiratory airway by remove shallow
prevent the vast distress such suctioning the accumulated
majority of as flaring of mouth using a bulb fluid, facilitates
cases of severe the ala nasi, syringe respiratory effort
meconium cyanosis, and helps
aspiration syndrome dyspnea and prevent further
(MAS). abnormal aspiration
breath sound

RR should be Note the pitch and Initially, a strong Flaring of the ala nasi
within normal intensity of the cry cry increases not observed any more
range(30 of the newborn alveolar pressure
60cpm) of oxygen and
produces the
 necessary
chemical
changes to
convert fetal to
neonatal
circulation, so
that the heart
rate increase to
175-180uterus

Absence of Nose and mouth were

mucus free of mucus
secretions in secretion
the nose and
mouth

Initiation of
good cry Good cry was initiated

Risk for The patient is at risk The newborn Monitor vital signs Determine any At the end of my care,
infection r/t for infection will have abnormal the newborn s vital
immature because of normal vital changes, raise in signs will remain
immune meconium staining. signs during temperature may within normal range
system Newborns that were my shift indicate
meconium stained infection
during the delivery Newborn is free of
is at high risk for The newborn Allows signs and symptoms
infection because of will not recognition of of infection such as
potential ingestion manifest signs abnormal fever and fatigue
of meconium. of infection findings and
such as fever allow prompt
and chills intervention if
complication
occurs

Mother will fully

Washing hands Hand washing is understood the
before and after the single best importance of
providing care way to avoid breastfeeding in
spreading relation to
pathogen strengthening the
immunity

Encourage mother Colostrum and

to breastfeed the breast milk
newborn contain high
exclusively amounts of
immunoglobulin
A, which
provides passive
immunity and
helps reduce
infection

Wearing gloves to Gloves reduce

maintain asepsis the possibility of
when providing transmitting
direct care and disease
when in contact
with blood or body
secretions

Monitor WBC Increased

count above production of
11,000/mm3 leukocytes
usually indicates
the presence of
bacterial
pathogens

Instilling eye Instill

ointment ophthalmic
(gentamicin drops or
ointment) ointment to
provide
prophylaxis
against
opthalmia
neonatorum