Sie sind auf Seite 1von 21

CUES/ DATA Subjective: n/a Objective: Preterm birth (34 wks and 2days) With Oxygen hood regulated

at 10 liters per minute RR:58 cycles/ min Episodes of apnea (6- 10 secs) O2 saturation of 91%

NURSING DIAGNOSIS Ineffective breathing pattern related to immature neurologic and delayed pulmonary development

RATIONALE A premature lung is structurally underdevelope d for postnatal life. To add, the premature delivery and the inadequate pulmonary surfactant. A deficiency in surfactant, which functions to decrease the surface tension within the alveoli. Without surfactant, the infant experiences diffuse atelectasis, decreased pulmonary compliance, ventilation perfusion mismatching, and significant

GOALS/ OBJECTIVES After 30 minutes of nursing interventions, the infant will experience an effective breathing pattern as manifested by -

NURSING RATIONALE EVALUATION INTERVENTIONS INDEPENDENT: After 30 minutes (1) assess RR (1) of nursing and pattern assessment interventions, provides goal is partially information met, the infant about experienced an neonates effective ability to breathing pattern initiate and as manifested by sustain an Infants RR effective is between - Infants breathing 40 and 60 RR was pattern between Infant will (2) 40 and 60 experience (2) provide respiratory assistance no apnea - Infant assistance as helps the experienc needed (oxygen newborn by ed less hood) clearing the episodes airway and of apnea promoting oxygenation (3) position infant (3) lying on on side with a the side rolled blanket position behind his back facilitate breathing (4) provide tactile (4) stimulation during stimulation periods of apnea of the sympathetic nervous

increase in the work of breathing. SOURCE; Gellis and Kagans Current Pediatric Therapy by Burg Ingelfinger p. 261

system increases respiration Delmars MaternalInfant Nursing Care Plans 2nd edition by Karla Luxner p. 223







EVALUATION After 1 hour of intervention, the goal is fully met. The neonate maintained a stable body temperature at 36 .7C evidenced by:

Subjective: N/A Objective: Gestational age of 34 weeks 2/7 Current weight: 2.0 kgs Neurological status: LOC: Lethargic Capillary refill time of 3 seconds. Integumentary Status: pale legs, Moderate pallor cool and dry skin Turgor: less than 3 seconds

Ineffective thermoregulation related to immaturity and lack of subcutaneous and brown fat

The preterm newborn has a great deal of difficulty attaining body temperature because she has a relatively large surface area per kilogram of body weight. In addition, because the infant does not flex the body well but remains in an extended position. Rapid cooling from evaporation is likely to

After 1 hour of nursing intervention, patient will maintain normal body temperature from 36.5-37.5 INDEPENDENT: 1. Staff members will take steps to maintain neonates body temperature at normal level. Pt. will have a and warm, dry skin Monitor the neonates body temperature until discharge To determine the need for intervention and the effectivene ss of therapy. Drying quickly and placing and placing on a warm, dry surface prevent heat loss from

Dry newborn thoroughly and quickly and discard the wet blanket. Place the infant under a pre warmed radiant warmer.

1. staff members kept neonates body temperature at normal level. neonate has warm, dry skin

neonate is placed in the isolation room Temperature: 35.5 C Mild shivering Baby is placed in an extended position Poor muscle tone Labs: Increased Hemoglobin (198 g/l) increased Hematocrit (0.58 g/l) increased WBC (10.3 x 10 d/l)

occur. The preterm infant has little subcutaneous fat for insulation and poor muscular development does not allow the child to move actively as the older infant does to promote heat. The preterm infant also has limited amount of brown fat; special tissue present in newborns to maintain body temperature.

evaporation. Avoid placing Cold surface infant on cold and surface or using instrument cold instrument increase in assessment. heat loss by conduction Ambient temperature of the room where the newborn is kept should be monitored Mummify and use thick blankets to cover the patient Teach the mother about the infants need for warmth and to keep the infants head covered To prevent excessive cooling.

Helps conserve heat in the body The infants head provides a large surface area for heat loss 2. parents expressed understandin g of neonates thermoregula tory disturbance and thermoregula tion

2. parents will express understanding of neonates thermoregulat ory disturbance and thermoregulati on

Source: Maternal and Child Health Nursing, 4th Ed. By Pillitteri, p.741

Teach family members about: -signs and symptoms of altered body temperature, such as cool extremities. - factors in home that contribute to neonatal heat loss and ways to minimize heat loss -importance of contacting a health care provider when problems related to temp regulation

Careful teaching allows family members to take an active role in maintaining the neonates health. Sources: Ladewig et al. Contemporary MaternalNewborn Nursing care 6th ed. P645 Taylor Et.Al Nursing Diagnosis Reference Manual 6th Ed. pp. 525526




GOALS/EXPECTED OUTCOMES After 1 day of nursing intervention, the neonate will receive adequate fluid and nutrients for growth during hospitalization:



EVALUATION After 1 day of nursing intervention, the goal is partially met, as evidenced by: 1. established an effective suck and swallow reflexes, allowing for adequate nutritional intake

Subjective: N/A Objective: Absent sucking reflex Birth weight: 2.3 kgs Current Weight: 2.0 kgs Ideal body weight: 2.2 4 kgs Stool characteristic s: loose, brown with tinge of green in color Type of feeding: discontinuati on of OGT,

Imbalanced nutrition: less than body requirements related to ineffective suck reflex

Nutritional problem arise with the preterm infant because the body is attempting to continue to maintain the rapid rate of intrauterine growth. Therefore, the preterm newborn requires a larger amount of nutrients in a diet than the mature infant does. Nutritional problems are

INDEPENDENT: 1. establish effective suck and swallow reflexes, allowing for adequate nutritional intake Assess the neonates sucking pattern. Try to correct ineffective sucking pattern Make sure the neonates tongue is properly positioned under the nipple of the mother To help eliminate ongoing difficulties

To enable the neonate to suck adequately

breastfed. Poor muscle tone pale conjunctivae Pale mucous membrane

compounded by the preterm infants immature reflexes, which makes swallowing and sucking difficult.

2. maintain good skin turgor, moist mucous membrane and flat , soft fontanels

(Maternal & Child health Nursing, 4th Ed. By Pillitteri, p.739)

Monitor the neonate for signs of dehydration, such as poor skin turgor, dry mucous membranes, increase or concentrated urine, & sunken fontanels and eyeballs. Assess the need for gavage feeding

To establish the need for immediate medical intervention

2. maintained good skin turgor, moist mucous membrane and flat , soft fontanels

The neonate may temporary require an alternative means of obtaining adequate fluid and calories

CUES/ DATA Subjective: -N/a since a potential diagnosis Objective: - 34 2/7 weeks of gestation - Immature gag reflex - Absence of sucking reflex - With OGT - RR: 52 breaths per minute

NURSING DIAGNOSIS Risk for aspiration related to premature infants impaired sucking reflex

GOALS/ OBJECTIVES The anatomic After 2 hours and functional of nursing interventions, immaturity of the infant will preterm not infants elevate experience their risks for aspiration minor and - the infant will more maintain clear significant complications, breath sounds like aspiration in which entry of secretions, solids, or fluids into the trachea passages is high. All newborns have poor muscle tone of the cardiac sphincter of the esophagus, thus causing


NURSING INTERVENTIONS INDEPENDENT: (1) elevate head of bed or place child in semi Fowlers position, or position head of the baby upright

RATIONALE (1) semi fowlers relaxes tension of the abdominal muscles, allowing for improved breathing (2)to allow the infant to rest

EVALUATION After 2 hours of nursing interventions, the infant did not experienced aspiration - the infant maintained clear breath sounds

(2) observe for signs to stop feeding momentarily, such as elevated eyebrows, wrinkled forehead (3) burp frequently because of excessive air swallowing

(3) infants are particularly subject to accumulation of gas in the stomach while feeding, and this can cause considerable

regurgitation. Newborns cough reflex is not well developed. Moreover, during the first few days of life, the newborn has increased mucus.

(4) hold an infant with his head elevated during feeding and position her in an infant seat after feeding

agitation to the child unless it is burped (4)such positioning uses gravity to prevent regurgitation of stomach contents and promotes lung expansion (5) the child and the family members must demonstrate the ability to ensure adequate home care before discharge Source: Nursing Diagnosis Reference

(5)instruct the family members in the home care plan

Source: Ladewig et al. Contemporary MaternalNewborn Nursing care 6th ed. P 653

Manual 6th edition by Ralph and Taylor pp. 394- 395 CUES/DATA Subjective: NURSING DIAGNOSIS RATIONALE Phototherapy exposes the newborn to high intensity light. Because it is not known if phototherapy injures the delicate structure of the eye, particularly the retina, it is important to use eye patch over the closed newborns eyes. Skin breakdown and fluctuation of temperature is also possible considering that the infant has delayed growth and development GOALS and OBJECTIVES After 8 hours of nursing interventions the neonate will be free of injury Infant did not have corneal irritation or drainage, skin breakdown, or major fluctuation in temperature. NURSING RATIONALE INTERVENTIONS INDEPENDENT: (1)Cover babys eyes with eye patches while under phototherapy lights. (2) Make certain that eyelids are closed prior to applying eye patches. (3) Remove baby from under phototherapy and remove eye patches during feeding. (4) Inspect eyes each shift for conjunctivitis, drainage and corneal abrasions due to irritation (1)Protects retina from damage due to high intensity light. (2)Prevents corneal abrasions. EVLUATION After 8 hours of nursing interventions, the goal is fully met. Neonate was free of injury. The infants eyes are protected, skin is intact, and maintained a stable temperature.

Risk for injury related to use n/a since it of is a phototherapy potential light diagnosis

Objective: -10 days old -temperature: 36.2C -jaundiced skin - patient is in photo therapy for 4 days - on breastmilk, OGT feeding -consumes five diapers/day -labs:

(3) Provides visual stimulation and facilitates attachment behaviors. (4)Prevents or facilitates prompt treatment of purulent conjunctivitis.

increased bilibrubin levels

and ineffective thermoregulation. Source: Ladewig et al. Contemporary MaternalNewborn Nursing care 6th ed. P758

from eye patches. (5) Administer thorough perianal cleansing with each stool. (6) Provide minimal coverage only of diaper area.

(7) Avoid use of oily applications on the skin. (8) Reposition baby every 2 hours.

(9) Observe for bronzing of skin.

(10) Place plexiglas shield

(5) Frequent defecating increases risk of skin breakdown. (6) Provides maximal exposure, shielded areas become more jaundices, so maximum exposure is essential. (7) Prevents superficial burns on skin. (8) Provides equal exposure of all skin areas and prevents pressure areas. (9) Bronzing is related to use of phototherapy with increased direct bilirubin levels or liver damage; may last for 2-4 months. (10)Hypothermia and

between baby and light. Monitor babys skin and core temperature frequently until tmperature is stable.

(11) Check axillary temperature.

hyperthermia are common complications of phototherapy. Hypothermia results from exposure to lights, subsequent radiation, and convection losses. (11) Hyethermia may result from the increased environmental heat.Additional heat from phototherapy lights frequently causes rise in babys temperature. Fluctuations in temperature may occur inresponse to radiation and convection.

CUES/ DATA Subjective: -n/a since a potential diagnosis Objective: patient is diagnose d with neonatal sepsis upon admission - -RR; 58 cycles/mi n - HR: 148 bpm - Labs: Increased WBC levels

NURSING DIAGNOSIS Risk for infection r/t spread of pathogens secondary to identified sepsis and immature immune system

RATIONALE The newborns immune system is not fully activated until some time after birth. Limitation in the newborns inflammatory response result in failure to recognize, localize, and destroy invasive bacteria thus, increasing risk for infection.

GOALS/ OBJECTIVES After 8 hours of nursing interventions the infant will not experience spread of infection as manifested by - Infants HR remains <160 bpm - RR is <60 cycles/ min

NURSING INTERVENTIONS INDEPENDENT: (1) ensure that all people coming in contact with infant wash their hands well before & after touching the baby (2) ensure that all equipment used for infant is sterile, scrupulously clean & disposable. Do not share equipment with other infants (3) place infant in isolette/ isolation room per hospital policy



After 8 hours of (1) handwashing nursing prevents the interventions, the spread of goal is fully met. pathogens coming The infant did from the infant to not experienced the caregiver and spread of vice versa infection as (2) this would manifested by prevent the spread - Infants of pathogens to HR the infant from remained equipment <160 bpm - RR was <60 cycles/ min (3) placing the infant in an isolette allows close observation of the ill neonate & protects other infants from

Source: Ladewig et al. Contemporary MaternalNewborn Nursing care 6th ed. P. 580

infection (4) maintain (4) a neutral neutral thermal thermal environment environment decreases the metabolic needs of the infant. The ill neonate has difficulty maintaining a stable temp. (5) assess TPR & (5) assessments BP, auscultate provide breath sounds information about the spread of infection, increased RR and HR, decreased BP are signs of sepsis. Spread of infection may cause resp. distress (6) provide (6) resp. support respiratory may be needed support (oxyhood) during the acute phase of the infection to prevent additional physiological stress (7) feed infant as (7)nutritional ordered (OGT) needs may

(8) monitor lab results as obtained. Notify care giver of abnormal findings

(9) monitor infant for hypoglycemia, jaundice, development of thrush, or signs of bleeding

DEPENDENT: (10) administer IV fluids as ordered (D10IMB) (11) administer antibiotics as

increase during infection while the infant may feed poorly. OG feedings ensure that nutrient needs are met if the infant is too ill to suck effectively (8) lab results provide information about the pathogen and infants response to illness and treatment (9) assessments coagulationprovide information about the development of complications of infection: hypoglycemia, hyperbilirubenia, opportunistic infections, and coagulation deficits (10) IV fluidsnhelp maintain fluid balance (11) antibiotics act to inhibit the


growth of bacteria and destruction of bacteria. Delmars Maternal- Infant Nursing Care Plans 2nd edition by Karla Luxner p. 237


Nursing Diagnosis


Goals and Objectives After 8 hours of nursing intervention




Objective: Patient is on photothera py for 4 days Consumes 5 diapers per day Slightly jaundice in color Dry skin Patient in supine position Has no clothes on during photothera py, only mittens, socks, and diapers Has eye

Risk for Impaired skin integrity related to exposure to high intensity light secondary to phototherapy

The newborn lies in one position for a long period of time that may result in skin breakdown. Due to lack of adipose tissue, the pressure exerted by bony prominences on the skin is greater thus increases the risk of skin breakdown.

1. Patients skin will remain intact INDEPENDENT: No signs of skin breakdown

After 8 hours of nursing intervention, goal is fully met. Patients skin remained intact as evidenced by: Patient position changes will allow exposure of the phototherapy lights to all areas of the body that are uncovered. Pressure areas may develop if newborn lies in one position for an extended period of time. No signs of skin breakdow n

Change position every 2 hours

Source: Ladewig et al.

cover during

Contemporary MaternalNewborn Nursing care 6th ed. P763

Monitor skin for rashes and bronzing every 8 hours. Inspect perianal area after each diaper change for signs of breakdown

Patient may develop a maculopapular rash which is transient side effect of phototherapy Newborns under phototherapy lights have increased loose green acidic stools which can be irritating to the skin. The diaper area should be thoroughly cleaned after each soiled diaper to prevent skin breakdown. Lotions and ointments may cause skin to burn if applied to exposed areas during phototherapy.
Source: Ladewig et al. Contemporary MaternalNewborn Nursing care

Avoid using lotions or ointments on the newborns skin

6 ed. P759- 761




Outcome Criteria




Dx: Ineffective thermoregulation related to immature temperature control and decreased subcutaneous body fat.

Plan: to monitor newborn closely to maintain temperature and prevent hyperthermia and cold stress

1. Infants body temperature will remain within normal axillary range, 36.537 degrees Celsius (Glass, 1999, p. 188).

1. Monitor axillary temperature at least every 8 hours; more frequently for infants at high risk.


Long-term: Newborn will be able to sustain adequate/normal self thermoregulation.

2. Mother will verbalize possible methods of heat loss & demonstrate understanding of conduction, convection, radiation, & evaporation within 12 hours.

2. Provide heat/warm the newborn using incubators, radiant warmer, swaddling, and skin-to-skin contact.

1. Regular temperature monitoring will identify adequate or inadequate thermoregulation (Glass, 1999, p.188). Axillary temperature is good indicator of newborns surface temperature (Glass, 1999, p. 188).

1. Newborn self maintains adequate body temperature for 24 hours prior to discharge.

Short-term: Provide assistance and support to maintain adequate/normal temperature

3. Mother will demonstrate maintenance of a neutral thermal environment within 24 hours.

3. Maintain thermal neutral environment and avoid situations that might predispose the infant to heat loss, such as cool air, drafts, bathing, and cold bedding.

2. To warm the newborn and adequately maintain accepted thermal range (Wong, 2003, p. 371).

2. Mother demonstrates effective maintenance of neutral thermal environment within 24 hours.

3. Mother verbalizes methods of possible heat loss within 12 hours.

4. Mother will demonstrate proper skin-to-skin warming technique prior t discharge.

3. To maintain stable body temperature of the newborn and decrease the possibility of heat loss through conduction, convection, radiation, & evaporation (Wong, 2003, p. 371).

4. Mother demonstrates proper skin-to skin warming technique prior to discharge.