ASSESSMENT Sub.

data: The mother complained baby have bluish discoloration

NURSING DIAGNOSIS

GOAL

PLANNING Assess the patient general

IMPLEMENTATION Assess the patient general condition Assessed the

EVALUATION

Decreased cardiac output related to reduced myocardial functions as Improve the cardiac output

condition Assess the nutritional status of the child Administer the IV fluid Advice to parents give the good nutritional food To maintain the input-output charts

nutritional status of Improved child cardiac output the child Administered the IV fluids Advised the parents give the good nutritional food To maintained the input output charts

Obj.data: The baby have been cyanosis

evidenced by cyanosis

ASSESSMENT Sub.data: The mother complained baby have breathing difficult

NURSING DIAGNOSIS

GOAL

PLANNING Assess the patient general

IMPLEMENTATION Assess the patient general condition Provide the appropriate position Administer the nebulization Administered O2 supply Check the vital signs Administer the medication

EVALUATION

Impaired gas exchange to disturbed pulmonary blood To improve the breathing and airway clearance

condition Provide the appropriate position To administer the nebulization Administer O2 supply To check the vital signs Administer the medication

Improved the breathing clear the airway

flow as evidenced maintained Obj.data: The baby have been dyspnea by dyspnea

ASSESSMENT Sub.data: The mother complained baby have weakness and vomiting fatigue

NURSING DIAGNOSIS

GOAL

PLANNING Assess the patient general

IMPLEMENTATION Assess the patient general condition Administered the IV fluids Encourage to the babys or child to take the oral fluids Administer the medication Give the psychological support

EVALUATION

Deficient fluid volume related to active fluid volume loss due to vomiting and diarrhea Improve the fluid intake

condition Administer the IV fluid To encourage to the babys or child to take the oral fluids To administer the medication Give the psychological support

Administer and encouraged to the fluids and maintain the fluid & electrolyte balance

Obj.data: The baby have the fluid loss

ASSESSMENT Sub.data: The mother complained baby have dizziness

NURSING DIAGNOSIS

GOAL

PLANNING Assess the patient general

IMPLEMENTATION Assess the patient general condition Provide the confortable bed& position administer the O2 supply maintain the breathing & circulation Give the psychological support

EVALUATION

In effective tissue perfusion related to hemorrhage & inadequate Improve the oxygen level

condition Provide the confortable bed& position To administer the O2 supply To maintain the breathing & circulation Give the psychological support

To improve the oxygen delivery

Obj.data: The baby is looking dull and not having eye to eye contact

hemoglobin to transport of oxygen across alveolus & capillary membrane

ASSESSMENT

NURSING DIAGNOSIS

GOAL

PLANNING

IMPLEMENTATION Assess the patient general condition Provide the confortable table passion administer the medication

EVALUATION

Sub.data: The mother complained baby have running nose Rise for infection related to chronic illness as Obj.data: evidenced by The baby have erythema or nose block & swelling running nose

Reduce the infection

Assess the patient general condition Provide the confortable table passion

Reduced the running nose

To administer the medication administer the To give the medication nebulization give the Give nebulization psychological Give psychological support support Avoid the parenteral anxiety Avoid the parenteral anxiety

ASSESSMENT Sub.data: The mother complained the baby have weakness & weight loss

NURSING DIAGNOSIS

GOAL

PLANNING Assess the patient general condition Asses the nutritional status of the child Provide balance diet Give health education about balanced diet Daily weight checking Provide psychological support

IMPLEMENTATION

EVALUATION

Obj.data: The baby have weight loss and delayed growth and development

Altered nutrition less than body requirements related to excessive energy demands required by increased cardiac work load as evidenced by weakness

Improve the nutrition and maintained balance nutrition

Assess the patient general condition Asses the nutritional status of the child Provide balance diet Improved the Give health nutrition education about balanced diet Daily weight checking Provide psychological support

ASSESSMENT Sub.data: The mother complained the baby have nose block

NURSING DIAGNOSIS

GOAL

PLANNING Assess the patient general condition Provide the comfortable passion Suctioning should be done Administer the O2 Administer the nebulization Advice the patient to do coughing exercises

IMPLEMENTATION

EVALUATION

Ineffective airway clearance related to altered level of Clear the airway consciousness improve the breathing

Obj.data: The baby have dyspnea

Assess the patient general condition Provide the comfortable passion To maintain airway and Suctioning should breathing be done Administer the O2 Administer the nebulization Advice the patient to do coughing exercises

ASSESSMENT Sub.data: The mother complained the baby have fever

NURSING DIAGNOSIS

GOAL

PLANNING Assess the patient general condition Provide the comfortable passion Administer the cold compress and cold sponge Administer the IV fluid Advice to parents provides good nutritional support

IMPLEMENTATION

EVALUATION

Obj.data: The baby have pyrexia

Risk for imbalance baby temperature related to inflammatory process

To reduced the hyper temperature maintain he balance of the temperature

Assess the patient general condition Provide the comfortable passion Reduced the hyper Administer the cold temperature compress and cold sponge Administer the IV fluid Advice to parents provides good nutritional support

ASSESSMENT Sub.data: The mother complained the

NURSING DIAGNOSIS

GOAL

PLANNING Assess the patient general condition Provide the comfortable

IMPLEMENTATION Assess the patient general condition Provide the comfortable passion

EVALUATION

baby have itching Impaired skin and erythema integrity related to edema diaphoresis Obj.data: The baby have skin integrity To maintain the skin hygiene

To maintain the skin Maintained skin hygiene medication To advice to the parent goal nutritional diet Give the psychological support hygiene

passion skin hygiene To administer the medication To advice to the parent goal nutritional diet Give the psychological support

To maintain the To administer the

ASSESSMENT Sub.data: The mother complained the child have less activity

NURSING DIAGNOSIS

GOAL

PLANNING Assess the patient general condition

IMPLEMENTATION Assess the patient general condition Provide the active and passive exercises Administer the medications Administer the oxygen supply

EVALUATION

Activity intolerance related to cyanosis and Improve the activity

Provide the active and passive exercises Administer the medications Administer the oxygen supply

Improved the activity

Obj.data: The child have less activity

dyspnea