Nursing Planning Implementation Evaluation Diagnoses/Analysis (Expected Client (Nursing Activities with NIC (Evaluate Each Expected Client (List 2 Nursing Diagnoses Outcomes) Intervention Outcome-If Not Met Discuss Reason in Order of Priority; 3-part Label & Page # Tailored to and Proposed Changes in Client Care) statement for actual Your Client) diagnoses) Infant will maintain a Teach parents taught how to Goal met aeb infant maintained patent airway at all use bulb syringe immediately. patent airway, demonstrated how to Risk for Ineffective times while on my shift. use bulb syringe, and able to Airway Clearance r/t Assess infant for patent identify factors that can inhibit excessive oropharyngeal Parents will airway q2h. effective airway. mucous demonstrate how to use bulb syringe while on Educate parents on factors my shift. that inhibit effective airway clearance such as smoking Parents will identify during discharge teaching. factors that can inhibit effective airway clearance while on my shift. Infant will maintain Encourage skin-to-skin Goal partially met aeb infant Effective Breastfeeding r/t effective breastfeeding contact. breastfeeding well, and mother infant gestational age > 34 during my shift. satisfied. Weight taken on night weeks aeb latching, Encourage breastfeeding on shift, but I did not get to retrieve sucking, and appears to be Infant will maintain demand. that information from computer full. normal growth patterns thus, I cannot confirm that the while on my shift. Provide mother with written infant maintained normal growth (I chose this not as a record to monitor patterns. priority diagnosis, but Mother will verbalize breastfeeding sessions. because I had not satisfaction with completed a care plan on breastfeeding process Assess nipples for pain, it yet.) while on my shift. soreness, and irritation. Provide Lanolin prn. Assess infant weight daily.
Nursing Diagnoses/Analysis (List 2 Nursing Diagnoses in Order of Priority; 3-part statement for actual diagnoses) Planning (Expected Client Outcomes) Implementation (Nursing Activities with NIC Intervention Label & Page # Tailored to Your Client) Evaluation (Evaluate Each Expected Client Outcome-If Not Met Discuss Reason and Proposed Changes in Client Care) Risk for Ineffective Airway Clearance r/t excessive oropharyngeal mucous Infant will maintain a patent airway at all times while on my shift. Parents will demonstrate how to use bulb syringe while on my shift. Parents will identify factors that can inhibit effective airway clearance while on my shift. Teach parents taught how to use bulb syringe immediately. Assess infant for patent airway q2h. Educate parents on factors that inhibit effective airway clearance such as smoking during discharge teaching. Goal met aeb infant maintained patent airway, demonstrated how to use bulb syringe, and able to identify factors that can inhibit effective airway. Effective Breastfeeding r/t infant gestational age > 34 weeks aeb latching, sucking, and appears to be full. (I chose this not as a priority diagnosis, but because I had not completed a care plan on it yet.) Infant will maintain effective breastfeeding during my shift. Infant will maintain normal growth patterns while on my shift. Mother will verbalize satisfaction with breastfeeding process while on my shift. Encourage skin-to-skin contact. Encourage breastfeeding on demand. Provide mother with written record to monitor breastfeeding sessions. Assess nipples for pain, soreness, and irritation. Provide Lanolin prn. Assess infant weight daily. Goal partially met aeb infant breastfeeding well, and mother satisfied. Weight taken on night shift, but I did not get to retrieve that information from computer thus, I cannot confirm that the infant maintained normal growth patterns.
3440_acd_careplan_graded.docx