LORMA COLLEGES CON TEMPLATE
NURSING CARE PLAN
RELATED LEARNING EXPERIENCE
Students Name:
CAMAT, John Carlo O.
Rotation: 4th Rotation
Area: Labor and Delivery Room
YR LEVEL AND SEC
II-PATERSON
Date: Mar. 25, 26, 31, Apr. 1, 2
Clinical Instructor: Mrs. Cherry Sharon Catli
PROBLEM: Oxygen saturation of 75
Diagnosis: Impaired gas exchange
PRIORITIZATION: 1st Priority
Assessment
Subjective:
-
Objective:
- The newborn
appeared pale blueish
in color and cold,
weak pulses, poor
perfusion with O2
Sat of 75, decreased
capillary refill, and
persistent
bradycardia with CR
of 55. She has also a
minimal response to
stimuli and muscle
tone and respiration
are absent. APGAR
score was checked
which is interpreted
as “Severely
Depressed”
Nursing Diagnosis
Impaired gas exchange
related to ventilationperfusion imbalance as
evidenced by persistent
bradycardia
Date: March 31, 2022
Planning
Implementation
Rationale
Evaluation
GOAL FULLY MET
Independent
Short Term:
After 5 minutes of nursing
intervention, the newborn will
be able to improve gas
exchange and arterial blood
gases will maintain within
normal ranges
Long Term:
After 3 days of nursing
intervention the newborn will
attain normal
breathing pattern
- Auscultate breath
sounds, noting areas
of decreased airflow
or presence of
adventitious sound
- Presence of wheezes
may indicate
bronchospasm/ retained
secretions
- Assess respiratory
rate, depth, and ease,
periods of apnea.
- Rapid and shallow
breathing patterns and
hypoventilation affect gas
exchange
- Assess newborn for
skin color and
perfusion.
- Apnea can cause tissue
hypoxia leading to poor
tissue perfusion with
resulting in changes in skin
color
- Monitor for signs of
hypercapnia
- Hypercapnia is the
buildup of carbon dioxide
in the bloodstream.
- Monitor oxygen
saturation continuously
- Pulse oximetry is a
useful tool to detect
changes in oxygenation
Short Term:
After 5 minutes of nursing
intervention, the newborn
was able to improve gas
exchange and arterial blood
gases maintained within
normal ranges
Long Term:
After 3 days of nursing
intervention the newborn
attained normal
breathing pattern
Dependent
- Administer
continuous nasal airflow
of CPAP via a nasal
mask, or face mask
- Continuous positive
airway pressure (CPAP) is
administered for pretermbirth apnea thought to be
related to the collapse of
the airway
LORMA COLLEGES CON TEMPLATE
NURSING CARE PLAN
RELATED LEARNING EXPERIENCE
Students Name:
CAMAT, John Carlo O.
Rotation: 4th Rotation
Area: Labor and Delivery Room
YR LEVEL AND SEC
II-PATERSON
Date: Mar. 25, 26, 31, Apr. 1, 2
Clinical Instructor: Mrs. Cherry Sharon Catli
PROBLEM: Poor perfusion and decreased capillary refill
Diagnosis: Decrease cardiac output
PRIORITIZATION: 2nd Priority
Assessment
Subjective:
-
Objective:
- The newborn
appeared pale blueish
in color and cold,
weak pulses, poor
perfusion with O2
Sat of 75, decreased
capillary refill, and
persistent
bradycardia with CR
of 55. She has also a
minimal response to
stimuli and muscle
tone and respiration
are absent. APGAR
score was checked
which is interpreted
Nursing Diagnosis
Decreased cardiac
output related to
ineffective tissue
perfusion as evidenced
by decreased capillary
refill
Date: March 31, 2022
Planning
Implementation
Rationale
Evaluation
GOAL FULLY MET
Independent
Short Term:
After 8 hours of nursing
interventions, the patient will
maintain adequate cardiac
output to improve circulation,
as evidenced by:
- Assess the central
and peripheral pulses
- Pulses are weak, with
reduced stroke volume and
cardiac output
- Assess capillary
refill time.
- Capillary refill is slow
and sometimes absent
- HR 60 to 100 beats per
minute with a regular rhythm,
- Warm and dry skin, and a
normal level of consciousness.
Long Term:
After 2 days of nursing
interventions, the patient will
be able to demonstrate
- Warm, moist, and smooth
skin
- Peripheral pulses present and
strong
- Monitor oxygen
saturation and arterial
blood gasses.
- The normal oxygen
saturation should be
maintained at 90% or
higher
Dependent
- Administer fluid and
blood replacement
therapy as prescribed
- Maintaining an adequate
circulating blood volume is
a priority
- If the client’s
condition progressively
deteriorates, initiate
cardiopulmonary
- Shock unresponsive to
fluid replacement can
worsen to cardiogenic
shock
Short Term:
After 8 hours of nursing
interventions, the patient was
able to maintain adequate
cardiac output to improve
circulation, as evidenced by:
- HR 60 to 100 beats per
minute with a regular
rhythm,
- Warm and dry skin, and a
normal level of
consciousness.
Long Term:
After 2 days of nursing
interventions, the patient was
able to demonstrate
- Warm, moist, and smooth
skin
- Peripheral pulses present
and strong
as “Severely
Depressed”
- Normal capillary refill in less
than 2 seconds
resuscitation or other
lifesaving measures
- Normal capillary refill in
less than 2 seconds
- Normal ABG result
- Normal ABG result
LORMA COLLEGES CON TEMPLATE
NURSING CARE PLAN
RELATED LEARNING EXPERIENCE
Students Name:
CAMAT, John Carlo O.
Rotation: 4th Rotation
Area: Labor and Delivery Room
YR LEVEL AND SEC
II-PATERSON
Date: Mar. 25, 26, 31, Apr. 1, 2
Clinical Instructor: Mrs. Cherry Sharon Catli
PROBLEM: The newborn appeared pale blueish in color and cold
PRIORITIZATION: 3rd Priority
Assessment
Subjective:
-
Objective:
- The newborn
appeared pale blueish
in color and cold,
weak pulses, poor
perfusion with O2
Sat of 75, decreased
capillary refill, and
persistent
bradycardia with CR
of 55. She has also a
minimal response to
stimuli and muscle
tone and respiration
are absent. APGAR
score was checked
which is interpreted
as “Severely
Depressed”
Diagnosis: Ineffective thermoregulation
Date: March 31, 2022
Nursing Diagnosis
Planning
Ineffective
thermoregulation related
to immature
temperature control
Short Term:
After 1 hour of nursing
intervention, the newborn will
reestablish a normal
core body temperature
Long Term:
After 3 days of nursing
interventions, the newborn
will be able to sustain
adequate and normal
self-thermoregulation
Implementation
Independent
Rationale
- Monitor axillary
temperature
- Regular temperature
monitoring will identify
adequate or inadequate
thermoregulation
- Maintain a thermally
neutral environment and
avoid situations that
might predispose the
infant to heat loss
- To maintain a stable
body the temperature of the
newborn and decrease the
possibility of heat loss
- Reduce or eliminate
the sources of heat loss
in infants
- Thermoregulation
balances the heat
production and heat loss to
maintain the body
temperature
Dependent
- Provide warm using
radiant warmer and
skin-to-skin contact as
told by a physician
- Adequately maintain
accepted thermal range
Evaluation
GOAL FULLY MET
Short Term:
After 1 hour of nursing
intervention, the newborn
reestablished a normal
core body temperature
Long Term:
After 3 days of nursing
interventions, the newborn
was able to sustain
adequate and normal
self-thermoregulation