DAVAO DOCTORS COLLEGE

General Malvar St., Davao City

Nursing Program

NURSING CARE PLAN

Name of Patient: Baby boy Rojo Date of Admission: March 13, 2023 Room: DR-1
Age: Newborn Sex: Male Civil Status: Married Religion: N/A
Chief Complaint: Fetal Bradycardia Attending Physician: Dr. Vanguardia

Date / Time Cues Nursing Diagnosis Goals and Interventions Rationale Evaluation
Objectives

Subjective: Nsg Dx: After (8) hours of Independent After 8 hours of the
March 13, 2023 Impaired swallowing related nursing interventions Intervention: nursing interventions:
@7am  Upon delivery to meconium aspiration as the patient will be able  Place suction  With impaired
secretions were evidenced by endotracheal to: equipment at swallowing The Goal and
suctioned intubation  Demonstrate Objective was met
 No heart rate . effective the bedside, reflexes,
and chest rise swallowing and suction as secretions can The patient was able
 No spontaneous [diagnostic division:] without signs of needed. rapidly to:
movement Nutrition aspiration accumulate in  Swallow
 cyanosis  Remain free without signs of
Rationale/ Scientific from aspiration the posterior aspiration and
basis: (e.g., lungs pharynx and was able to
clear, upper trachea gain .5 kg of
Impaired temperature weight by the
increasing the
Objective: swallowing involves more within normal end of the shift.
time and effort to transfer range) risk of .
 mechanical food or liquid from  Show signs of aspiration.
ventilator the mouth to the stomach. It improvement
  endotracheal occurs when the muscles on the weight of  Observe for  These are all
tube size of 3 and nerves that help move the patient. signs of signs of
level 7 food through the throat and
 APGAR score of esophagus are not working aspiration swallowing
1 right. It could be temporary and pneumoni impairment.
 or permanent but both are a. Auscultate
fatal. .
lung sounds
after feeding.
Vital Signs: Note new
crackles or
 BP: 60/90 wheezing, and
mmHg note elevated
 Temp:36.5-
temperature.
37.5° C
 PR: 120 bpm Notify
 RR: on physician as
mechanical needed.
ventilator  Assess ability  If aspirated,
 Weight: 1.2 kg
to swallow a little or no
 Height: 18 inch
 Blood type: small amount harm to the
AB(+) of water. patient occurs.

 Weigh patient  This is to help

weekly. evaluate
nutritional
status.
Dependent
Intervention:

 Initiate a  The presence

dietary of new
consultation crackles or
for calorie wheezing, an
count and elevated
food temperature
preferences. or white
blood cell
count, and a
change in
sputum could
 indicate
aspiration of
food.

 Educate  It is common
patient, family, for family
and all members to
caregivers disregard
about necessary
rationales for dietary
food restrictions
consistency and give
and choices. patient
inappropriate
foods that
predispose to
aspiration.

 Classify food  Knowledge of

given to the the
patient before consistency of
each spoonful food to expect
if the patient can prepare
is being fed. the patient for
appropriate
chewing and
 swallowing
technique.

 If patient has
impaired  Feeding a
swallowing, do patient who
not feed until cannot
an appropriate sufficiently
diagnostic
workup is swallow
completed. results in
Ensure proper aspiration and
nutrition by possibly death
consulting with
physician for . Enteral
enteral feedings via
feedings, PEG tube are
preferably a generally
PEG tube in
most cases. preferable
to nasogastric
tube feedings
because
studies have
shown that
there is
increased
nutritional
status and
possibly
 improved
survival rates.

Reference: Doenges, M., Moorhouse, M., Murr, A. (2013). Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales.(13th Edition) DavisPlus.fadavis.com
Herdman, T. H., Kamitsuru, S. (2018). NANDA NURSING DIAGNOSIS: Definition and Classification 2018 -2020. (11th Edition). MediaCenter.thieme.co
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