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ASSESSMENT

NURSING DIAGNOSIS Imbalanced Nutrition: less than body requirements related to difficulty in normal feeding position

GOAL

NURSING INTERVENTION Independent: 1.Determine clients disorder(spina bifida). 2.Assess weight; measure/calculate body fat and other anthropometric measurements. 3.Help the mother hold the infant in as normal a feeding position as possible. Make certain that a supporting arm does not press against the lesion. 4.Weigh regularly/graph results 5.Health teaching/realistic explanation to the parents about the treatment planned for the child. .

RATIONALE

EVALUATION

Objective: Temp. 36.9C HR: 135bpm RR: 50cpm Height: 51cm. Wt. 5.5 pounds -poor skin turgor -

LTG: After 1 week of nursing interventions the infant will be able to maintain weight within 10% of birthweight from 5.5 to 6.05pounds.

-this factor can affect ingestion and/or digestion of nutrients. -to establish baseline parameters.

Goal met as evidenced by the infant maintain weight within 10% of birthweight from 5.5 to 6.05pounds.

-To maintain nutrition and to avoid pain for the baby.

-to monitor effectiveness of efforts. -so they can decide whether to continue breastfeeding.

ASSESSMENT

NURSING DIAGNOSIS Risk for infection r/t rupture or bacterial invasion of the neutral tube sac

GOAL

NURSING INTERVENTION Independent: 1.Note risk factors for occurrence of infection such as surgeries/invasive procedures. 2.Avoid exposed meningial sac to dry.

RATIONALE

EVALUATION

Objective: Temp. 38C HR: 140bpm RR: 59cpm Height: 51cm. Wt. 5.5 pounds -weakness -skin warm to touch -WBC elevated -irritation

LTG: After 8hrs. of nursing interventions the infants neutral tube will remains intact and be able to reduce axillary temp. from 38C to 37C.

Goal met as -to assess evidenced by the causative/contributing infants neutral factors tube will remains intact and be able to reduce axillary temp. from 38C to 37C. -it allows CSF to drain and microorganisms to enter. - to establish baseline parameters -to avoid crosscontaminations -to avoid infections

3.Monitor vital signs of the child 4.Use aseptic technique 5.Use sterile, moist, nonadherent dressing Dependent: 1.Give antibiotics as prescribed

-to reduce body temperature

ASSESSMENT

NURSING DIAGNOSIS Impaired skin integrity r/t required prone positioning

GOAL

NURSING INTERVENTION Independent: 1.Identify underlying condition such as surgical incision. 2.Assess blood supply and sensation(nerve damage) of affected area. 3.Note skin color, texture, and turgor. 4.Inspect surrounding skin for erythema, induration, maceration. 5.Periodically remeasure wound/lesion characteristics and changes observed. 6.Keep the area clean/dry, carefully dress wounds, support incision.

RATIONALE

EVALUATION

Objective: Temp. 36.9C HR: 135bpm RR: 50cpm Height: 51cm. Wt. 5.5 pounds -destruction of skin layers -poor skin turgor

LTG: After 1 week of nursing interventions the infants skin remains intact, without erythema or ulceration.

-to assess Goal met as causative/contributing evidenced by the factors. infants skin remains intact, without erythema or ulceration. -to evaluate actual/potential for impairment of circulation to lower extremities. -to assess extent of involvement/injury. -this is an abnormal signs.

-to monitor progress of healing.

-to promote optimal healing.