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123cardos Sga NCP
123cardos Sga NCP
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.
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.
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
Smart Gabrielle L. Cardos St.N
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