ASSESSMENT Subjective: Objective: Restlessness Abnormal breathing dyspnea Tachycardia v/s: PR- 190 RR- 95

DIAGNOSIS Impared gas exchange related to altered oxygen supply

PLANNING After 4 hours of continuous nursing intervention the patient will be able to demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within clients normal limits and absence of symptoms of respiratory distress

INTERVENTION -Monitor v/s -Elevate the head of the bed and position the client appropriately -Encourage frequent position changes every 2 hours and deep-breathing exercise and demonstrate -encourage adequate rest and limit activities to within client tolerance -reinforce adequate rest, while encouraging activity and exercise -provide psychological support -keep environment allergen free

RATIONALE -To gather baseline data - to maintain airway

EVALUATION After 4 hours of continuous nursing intervention the patient can able to demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within clients normal limits and absence of symptoms of respiratory distress goal met.

-promotes optimal chest expansion

-helps limit oxygen needs and consumption

-to decrease dyspnea and improve quality of life

-to reduce anxiety

-to reduce irritant effect of dust and chemicals on air -to treat underlying conditions

-administer medications as ordered

ASSESSMENT Subjective: Objective: Small Thin Unable to eat Weakness of muscle

DIAGNOSIS Risk for impared growth and development related to prematurity secondary to congenital disorder

PLANNING After 2 days of continuous nursing interventions the patient will be able to receive appropriate nutrition as indicated by individual needs

INTERVENTION -Monitor v/s -Treat child as normally as possible -Promote ageappropriate activities as condition allows

RATIONALE -to gather baseline data -

EVALUATION After 2 days of continuous nursing interventions the patient receives appropriate nutrition as indicated by individual needs goal partially met.

-to enhance muscle tone and strength, and appropriate body building -instruct parent of the patient to give a small frequent nutritious meals and snacks everyday -instruct the S/O to provide nutritious foods to the child -encourage parents -to reduce anxiety to give all the needs of the child -provide comfort to the child and to the S/O

ASSESSMENT Subjective: Objective: Small thin Weakness of muscle Poor muscle tone

DIAGNOSIS Imbalanced nutrition: less than body requirements related to inability to absorb nutrients secondary to congenital disorder

PLANNING After 5 days of continuous nursing interventions the patient will be able to gain appropriate weight

INTERVENTION -Monitor v/s -note age, body build, strength, activity and rest level -prevent or minimize unpleasant odor or sights -offer several small meals and snacks daily -determine whether a client prefers more calories in a particular meal -use flavoring agents

RATIONALE -to have baseline data -help determine nutritional needs -may have a negative effect on appetite and eating -

EVALUATION After 5 days of continuous nursing interventions the patient gain appropriate weight goal met.

-to enhance food satisfaction and stimulate appetite -to stimulate appetite

-encourage client to choose foods or have family member bring foods that seem appealing -promote pleasant, relaxing environment -promote adequate and timely fluid intake. Limit fluids 1 hour prior to meal -weigh regularly and graph results

-to enhance intake of foods -to reduce possibility of early satiety

-to monitor effectiveness of efforts