1. Ineffective Breathing Pattern related to increased secretions in the airways.
Objective data: the baby looks shortness of breath, anxiety, increased respiratory rate, and excessive secretions.
Goal: Ineffective breathing can be overcome.
Expected outcomes: infant no longer congested, calm baby, decreased respiratory rate, airway secretions in no longer exists.
Nursing Intervention:
1. Put the baby in a comfortable position, head elevated (eg held).
Rationale: good position to help loosen the airway.
2. Give oxygen and airway clear of secretions.
Rationale: Oxygen overcome the body's need for oxygen and clearing the airway would reduce blockages in the airway.
3. Collaboration with the doctor about antibiotics.
Rational: antibiotics to fight infection.
2. Imbalanced Nutrition, Less Than Body Requirements related to lazy drinking, diarrhea, and vomiting.
Objective data: The baby lazy drinking, diarrhea, and vomiting.
Goal: Disorders of nutrition can be addressed.
Expected outcomes: vomiting and diarrhea stopped, the baby would be fed.
Nursing Intervention:
1. Encourage the mother to keep breastfeeding.
Rationale: Breast milk contains IgA, high amounts that can provide immunity.
2. Auscultation bowel sounds.
Rational: decreased blood flow can decrease intestinal peristalsis.
3. Collaboration with physicians about the provision of drugs such as antibiotics and fluid administration.
Rational: antibiotics to fight infection which will aggravate the infection.
3. Fluid Volume Deficit related to diarrhea, vomiting, and a lazy drink.
Objective data:
- Poor turgor and dry skin.
- Dry mucous membranes.
- Hyperthermia.
- Lactation.
- Diarrhea.
- Vomiting.
Goal: The fluid volume returned to normal.
Expected outcomes: normal temperature, mucous membranes and the skin is no longer dry.
Nursing Intervention:
1. Instruct the mother still breastfeeding.
Rationale: Breast milk contains high amounts of IgA may provide immunity.
2. Supervise the input and output, record and measure the frequency of diarrhea and fluid loss.
Rational: changes greatly affect the quality of milk fluid requirements and increased risk of dehydration.
3. Collaboration with physicians about the administration of medication and fluid therapy.
Rational: fluid therapy can help reduce the interference of body fluids.
4. Hyperthermia related to the infection process
Goal: baby's body temperature back to normal.
Expected outcomes: no signs of hyperthermia
Nursing Intervention:
1. Monitor the patient's temperature (degrees and patterns); note sounds chills / diaphoresis.
Rational: temperature of 38.9 degrees to 41 degrees shows an acute infectious disease process. The pattern of fever may help in the diagnosis.
2. Monitor the temperature of the environment, limit or add bed linen, as indicated.
Rational: the temperature of the room or the number of blankets to be changed to maintain near-normal temperatures.
3. Give warm compresses bath; avoid the use of alcohol
Rational: to help reduce fever
4. Collaboration: Give antipyretics
Rational: used to reduce fever by central action on the hypothalamus, although the fever may be useful in limiting the growth of organisms, and increased autodestruksi from infected cells.
5. Collaboration : Give antibiotics
Rational: antimicrobial treat infections that cause disease.
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