John Doner

Nurs 215-106
2/23/14
NICU MINI PLAN OF CARE
Mothers Initials: V.G. Infants initials: I.G. M/F: Male
Mothers age: 24 Gestational age at delivery: 40.4 weeks
Gravida: 1 Para: 1
Maternal blood type: B+
Family members supporting infant: mother
Mothers past medical history: (if available)
Maternal chlamydia - Hx of untreated chlamydia infection, date of onset unknown, no data
on medications; mother did not present with chlamydia upon admission to HUP.
Prenatal care/Pregnancy history: mother reports scant prenatal care; had 2 visits with
Penn Medicine; total weight gain unknown; no reported prenatal complications other than
Hx of chlamydia
Medications used during pregnancy: None to report
Problems with previous births? N/A (mother is prime)
Maternal Psych/Social History: None to report; mother is married and has a college
education, mother denies drug or alcohol use
Maternal Risk Factors: STIs (chlamydia)
Fetal risk factors: None
Delivery date, time, and type: Cesarean section; primary; 15:20, 2/4/14
Delivery complications: Labor complicated by maternal fever; tachypnea (related to
metabolic syndrome. Baby had low bicarbonate levels.)
Newborn Assessment
Apgars: 8 @ 1 min; 9 @ 5 min Vital Signs: T: 98.4F P: 115bpm
R: 90 breaths/min
BP: 54/37 (43)
Gestational Age Assessment: 40.4 weeks Infants age in days: 4 days
IV Lines: central line
O2 requirements: 95-100%
Weight of infant at birth: 3,635 grams
Ballard Score at birth: N/A
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Feeding Status: bottle
Feeding Method: PO
Elimination: Voiding independently
Classify birth weight: AGA
Weight of infant presently: 3,670 grams
Applicable Lab Findings
GBS: Negative HIV: Negative Sickle cell: Unknown
Hepatitis B: Negative RPR: Not recorded Urine Tox: Negative
Blood type: B+ Rubella: Immune GC/Chlam: Negative
Blood Gas: pH 7.39 / PaCO2 369 mmHg / PaO2 41.6 mmHg / HCO3 22.4 mEq/L / Base
Ex/Ded -2.2 mmol/L
CBC: 29.7 > 15.1 < 402
Technological Interventions Required (not previously addressed):
Infant on RA since birth
Feeding tube
Central line
Developmental Care: Infant is swaddled and all care is done at once; this reduces stimuli and
helps the infant rest.
List and include detailed information on four parental teaching needs:
1. I would educate the mother on the importance of breastfeeding, as she is a
first-time mother and may not be familiar with its benefits. For the first few weeks,
most newborns will breastfeed every 2-3 hours. Signs of hunger include restlessness,
sucking motions, and lip movements. The baby should nurse from the first breast
until it feels soft, about 20 minutes. Then, the baby should be burped. After that,
she should offer the second breast if the baby is still hungry. If full, the mother
should start the next breastfeeding session with the other breast. If the infant has a
favorite breast and the other breast becomes sore and full, the mom should pump
to relieve the pressure and preserve her milk supply.
2. Infant bonding and care is also important. As noted above, feeding and suckling is
skin-to-skin contact, which promotes bonding and reinforcement of the parent-child
relationship. Even though her baby is currently in the ICN, the mother should also
focus on bonding with her infant when they both go home, looking at the baby and
having skin-to-skin contact. This can reduce the chance of postpartum depression
and reduce the uneasiness of being a first-time mom. She should learn to recognize
her babys signs that it is hungry, needs a diaper change, needs to be burped, is
playful, cooing, smiling, and being curious. Games like peek-a-boo, playing with
food, and showing pictures to the infant are important to promote bonding.
However, babies have an underdeveloped nervous system, so it is also important to
recognize when the infant is overstimulated and needs to rest. Finally, the mother
should also get enough sleep, ask for support from her husband, family, friends, and
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even neighbors.
3. The mom also needs social and family support. Her husband can be involved in her
and her babys care by bonding with the infant himself (using the above guidelines),
taking both mom and baby to doctors appointments and wellness checks, talking to
his wife about any feelings and mood swings that she may experience. While this can
be normal, worsening mood swings can be a sign of postpartum depression, which
can affect up to 25% of mothers. Signs and symptoms of postpartum depression that
she, her husband, and her friends and family must learn to recognize include
sadness, feelings of hopelessness, low self-esteem, guilt, a feeling of being
overwhelmed, sleeping and eating disturbances, exhaustion, social withdrawal, loss
of interest in doing normal activities, being easily frustrated, feeling of incapability
to care for the baby, and loss of sex drive. Treatment can include inclusion of social
support system, going to focus groups, counseling, medication, having a health diet,
exercise, and promoting healthy and adequate sleep cycles.
4. Finally, prevention of STIs and adequate education about birth control and family
planning is key. The mother has chronic undiagnosed chlamydia infections, which can
be asymptomatic in 50-70% of infected women. This can leave her sterile if
untreated. She should be tested and get her partner(s) tested. Chlamydia is
effectively treated by antibiotics such as doxycycline or erythromycin. The most
important teaching need is effective and safe use of condoms for sex. The birth
control pill, IUDs, rings, and sponges do not protect against STIs. Cervical diaphragms
only offer limited protection, and spermicide kills sperm but not the bacteria that
causes STIs.
Diagnosis Nursing Interventions Supportive Rationale for
Interventions
Expected
Outcomes/
Evaluations
Risk for
ineffective
infant
feeding
pattern
secondary to
nosicomial
nutritional
status
1) Monitor infant weight gain at
the same time each day on the
same day for duration of stay in
hospital
2) Monitor infant for poor skin
turgor, dry mucous membranes,
decreased or highly-concentrated
urine output, and sunken
fontanelles and eyeballs
3) Assess need for gavage
feeding
4) Monitor I/Os of infant every
2-3 hours
5) Discussion with parents on
importance of breastfeeding,
methods, tips, and goals (see
1) Monitoring weight gain is a
routine, standard method of
tracking nutritional status
2) These s/s are are
indicative of dehydration and
must be addressed quickly.
3) Infant may temporarily
need alternatives for feeding
in order to provide adequate
fluids and electrolytes. The
doctor may wish to continue
this babys IV fluids until he is
ready to fully utilize mothers
milk or formula.
4) This is a routine, standard
method to determine
The infant will,
upon discharge, be
within the normal
height and weight
for his age and
keep within the
normal percentile
limits on the
postnatal growth
chart.
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Teaching Need #1 above) adequate nutritional status;
most infants need 100-120
cal/kg/day and they can
excrete 5-10mL/kg/day in
stool.
5) The parents must be
educated as part of discharge
teaching on infant feeding
methods to ensure adequate
infant nutritional status
Risk for
unstable
blood glucose
level
secondary to
ineffective
breastfeeding
1) Monitor infant weight gain at
the same time each day on the
same day for duration of stay in
hospital
2) Assess neonate for symptoms
of low or high serum blood
glucose level (hypoglycemia:
hypotonia, lethargy, poor
feeding, jitteriness, seizures,
cyanosis, apnea, hypothermia;
hyperglycemia: frequent feeding,
increased thirst, presence of
glucose in urine, poor wound
healing, frequent urination,
stirring, increased fidgeting and
activity) and maintain patent
airway if indicated
3) Assess need for gavage
feeding
4) Discussion with parents on
importance of breastfeeding,
methods, tips, and goals (see
Teaching Need #1 above)
5) Discussion with parents on
knowledge of hypo-/hyper-
glycemia etiology, s/s, and
management to prevent future
episodes
1) Monitoring weight gain is a
routine, standard method of
tracking nutritional status
2) These are s/s of neonatal
hypoglycemia or
hyperglycemia, respectively,
and must be addressed
quickly to avoid seizures,
coma, and death
3) Infant may temporarily
need alternatives for feeding
in order to provide adequate
fluids and electrolytes and
maintain adequate blood
glucose levels. The doctor
may wish to continue this
babys IV fluids until he is
ready to fully utilize mothers
milk or formula.
4) The parents must be
educated as part of discharge
teaching on infant feeding
methods to ensure adequate
infant nutritional status
5) The parents must be able
to recognize signs that their
infant is receiving too little or
too much breast milk, as this
can destablilize blood glucose
levels
The infants blood
sugar will be WNL
for the next three
scheduled blood
glucose tests in the
ICN.
Risk for
Infection
related to
baby's
unhealed
1) Monitor and record
temperature as part of routine
vital signs every hour while
infant is in the ICN
2) Document and report any
1-2) Elevated temperature
can be indicative of infection
3) These are signs of
umbilical cord infection,
which may present with
The infant will
show no signs and
symptoms of
infection at his
next pediatric
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umbilical cord trending changes in infants
temperature
3) Assess umbilical cord site for
signs of infection: blood or pus
originating from stump,
cloudiness of cord stump, navel
redness and warmth, separation
of cord delayed past 2 weeks
4) Assess parents needs for
proper cord care (rubbing
alcohol, towels, diapers, cotton
swabs, etc.)
5) Evaluate parents knowledge
of proper umbilical cord care
(avoidance of baths until area is
fully healed, clean navel with
rubbing alcohol 4 times a day,
use a cotton swab to clear out
dried pus or debris, keep diaper
folded down below navel, prevent
poop from getting on cord, and if
so, clean with water first to
remove stool, then alcohol to
disinfect)
elevated temperature
4) It is important that the
parents have all the resources
and supplies they need for
proper umbilical cord care
5) It is important that the
parents have all the
knowledge and skills they
need for proper umbilical cord
care
well-child visit at 1
month of age.
Risk for
altered
parentinfant
attachment
related to
anxiety of
being a new
parent
1) Interview parents, noting their
perception of the situation and
individual concerns
2) Identify infants strengths
and vulnerabilities
3) Assess parent/child
interactions
4) Ascertain availability/use of
resources to include extended
family, support groups, and
financial resources
5) Evaluate parents ability to
provide a protective environment
and participate in reciprocal care
relationship
1) Parents may have concerns
or questions that need to be
addressed, since they are
first-time parents
2) Each child has own
temperament that affects
interactions with caregivers
3) Assessing the bond and
interactions between infant
and parent can reveal
strengths and weaknesses in
the parent-infant care
relationship
4) Social support and family
resources are important in
maintaining parent-infant
attachment
5) This can provide insight
into constructive
interventions and teaching
methods on maintaining
parent-infant care
Mother will report
no or minimal
issues or concerns
regarding care of
her child and her
self-perception and
emotional status at
her six-week
postpartum
well-woman visit.
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relationship
Risk for
sudden infant
death
syndrome
1) Assess prenatal and maternal
history, parental experience;
monitor the infants heart rate,
blood pressure, respiratory rate
and quality, depth of
respirations, breath sounds,
reexes, and response to touch.
2) Position infant on his/her
back when placed in the crib.
3) Elevate infants head slightly
when placed in the crib.
4) Maintain room at appropriate
temperature and avoid wrapping
the infant in heavy blankets.
5) Educate parents about risk
factors of SIDS. Instruct them on
ways to maintain a safe
environment in the home.
1) Assessment information
will assist in identifying
appropriate interventions.
2) Incidence of SIDS is higher
when the infant is placed in a
prone position.
3) This can decrease
abdominal pressure on
diaphragm and allow better
expansion of lungs.
4) Excessive heat has been
identied as a possible risk
factor.
5) Modication of current
practices can reduce risk and
prevent occurrence of SIDS.
Parents will
verbalize teaching
points regarding
maintaining a safe
environment for
baby, such as
proper infant
positioning in crib,
maintaining
appropriate room
temperature, and
monitoring infants
breath rate and
sounds, and heart
rate.
References:
1. Chapman, L. C., & Durham, R. F. (2010). Maternal-newborn nursing: The critical
components of nursing care. (1st ed., Vol. 1, pp. 315-332). Philadelphia, PA: F.A.
Davis Company.
2. Thompson, J. G. U.S. Department of Agriculture, (2011). Nutritional needs of
infants. Retrieved from National Agricultural Library website:
http://www.nal.usda.gov/wicworks/Topics/FG/Chapter1_NutritionalNeeds.pdf
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