NURSING CARE PLAN

Assessment

. Nursing Diagnosis

Scientific Basis

Goals/Objectives

Nursing

Rationale

Evaluation

SUBJECTIVE DATA:
N/A

IMPAIRED GAS
EXCHANGE related
to immaturity of
newborn's lungs and
lack of surfactant

With deficient
surfactant, areas
hypo inflation begin to
occur & pulmonary
resistance increase.
The lungs are poorly
perfused, affecting
gas exchange.

After 1-2 hour of

nursing interventions,
the neonate will be
able to improve
ventilation as
evidenced by:
infant's skin
becomes pinkish in
color
respiratory rate of
40-60cpm
infant will be
extubated and
weaned to nasal
CPAP support

INDEPENDENT
Assess respiratory
status, noting signs of
respiratory distress
(tachypnea, dsypnea,
grunting, retractions)
Assess skin color
for development of
cyanosis
Promote rest,
minimize stimulation
& energy expenditure

Tachypnea indicatea
respiratory distress
esp when RR is
>75cpm after the first
hour of life. Expiratory
grunting represents
attempt to maintain
alveolar expansion,
nasal flaring is a
compensatory
mechanism to
increaaw diameter of
nares & increase
oxygen intake.
Lack of
oxygenation will result
in cyanosis
To decrease the
metabolic rate &
oxygen consumption
Laboratory results
reveals & prevents
any further
complications

Goal Partially Met

After 1-2 hour of
nursing intervention
the infant ventilation
improved as
evidenced by:
Infant skin is pinkish
in color
RR of 60-70cpm
infant was extubated
and weaned to nasal
CPAP

OBJECTIVE DATA:
Newborn Preterm 29
weeks Age of
Gestation
Birth weight: 1060
grams Apgar Score:
4-intubated
Vital Signs: T- 35
C-35.5 C HR- 130150bpm RR- 7080cpm
Dyspnea noted
Expiratory grunting
and nasal flaring
noted
Skin pale to
cyanotic in color

Laboratory Studies
Chest X-ray - hazy
appearance (See
table)
BGA - Respiratory
Acidosis (See table)

Because surfactant
does not form until
the 34th week of
gestation, as many as
30% of low birth
weight infants and as
many as 50% of very
low birth weights
infant are susceptible.
Source: Maternal &
Child Health Nursing)

COLLABORATIVE
Monitor laboratory/
diagnostic status as
appropriatea

NURSING CARE PLAN

Assessment

. Nursing Diagnosis

Scientific Basis

Goals/Objectives

Nursing

Rationale

Evaluation

SUBJECTIVE DATA:
N/A

INEFFECTIVE
BREATHING
PATTERN related to
immature neurologic
& delayed pulmonary
development

A premature lung is
structurally
underdeveloped for
postnatal life. To add,
the premature
delivery & the
inadequate
pulmonary surfactant.
A deficiency in
surfactant, which
functions to decrease
the surface tension
within the alveoli.
Without surfactant the
infant experience
diffuse atelectasis,
decreased pulmonary
compliance,
ventilation, perfusion,
mismatching &
significant in the work
of breathing.

After 1-5 hour of

nursing intervention ,
the infant experience
effective breathing
pattern as evidenced
by:
RR will be between
normal range 4060cpm
shows no episodes
of apnea

INDEPENDENT
Assess respiratory
rate & pattern
Provide tactile
stimulation during
periods of apnea
Position infant on
side

Assessment
provides information
about the neonate's
ability to initiate &
sustain an effective
breathing pattern
Stimulation of the
sympathetic nervous
system increases
respiration
Lying on the side
position facilitates
breathing
Assistance helps the
newborn by clearing
the airway &
promoting
oxygenation

After 1-5 hour of

nursing intervention,
goal is fully met, the
infant experienced an
effective breathing
pattern as manifested
by:
RR is between
normal range 5560cpm
shows no episode of
apnea

OBJECTIVE DATE:
Preterm 29 weeks
Tachypnea noted
RR 70-80cpm
Episodes of apnea
O2 saturation 8590%

Source: Gelli's &

Kagan's Current
Pediatric Therapy by
Burg Ingelfinger

p.261

DEPENDENT
Provide respiratory
assistance as needed
as per Doctor's order
(See table)

NURSING CARE PLAN

Assessment

. Nursing Diagnosis

Scientific Basis

Goals/Objectives

Nursing

Rationale

Evaluation

SUBJECTIVE DATA:
N/A

INEFFECTIVE
THERMOREGULATI
ON related immaturity
and lack of
subcutaneous &
brown fat

The preterm newborn

has a great deal of
difficulty attaining
body temperature
because it 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 occur.
The preterm infant
has little
subcutaneous fat for
insulation & poor
muscular
development does
not allow the child to
move actively as the
older infant does to
promote heat. The

After 1-2 hour of

nursing intervention,
the infant will
maintain normal body
temperature as
evidence by:
Temperature of
36.5 C-37.5 C
Warm & dry skin

INDEPENDENT
Monitor the neonate's
body temperature
Place the infant
under pre warmed
radiant warmer and
dry thoroughly &
quickly
Avoid placing infant
on cold surface or
using cold instrument
in assessment
Incubator/Isolette
temperature should
be kept monitored

To determine the
need for intervention
& the effectiveness of
therapy
Drying quickly &
placing on warm, dry
surface prevent heat
loss from evaporation
Cold surface &
instrument increase
heat loss by
conduction
Helps conserve
heat in the body

After 1-2 hour of

nursing intervention,
goal is fully met, the
infant shows a stable
body temperature as
evidenced by:

OBJECTIVE DATE:
Preterm 29 weeks
Weight: 1060 grams
LOC: Lethargic
Capillary refill time
of 3 seconds
Intergumentary
Status: - Pale legs,
moderate pallor Cool & dry skin Turgor less than 3
seconds

Body temperature of
36.7 C
Infant has warm &
dry skin

preterm infant also

has limited amount of
brown fat; special
tissue present in
newborns to maintain
body temperature.
Maternal & Child
Health Nursing 4th
Ed. By Pilliteri p.741

NURSING CARE PLAN

Assessment

. Nursing Diagnosis

Scientific Basis

Goals/Objectives

Nursing

Rationale

Evaluation

SUBJECTIVE DATA:
N/A
OBJECTIVE DATA:
1 day old male
Skin jaundice in color
Exposed on double
phototherapy
Body Temp: 36.7
C-37 C
Laboratory:
High Bilirubin level
after 24 hours of age
151.8 umol/L (See
table)

RISK FOR INJURY

related to
Phototherapy light

Phototherapy
exposes the newborn
to high intensity light.
Because it is not
known if phototherapy
injures the delicate
structure of the eye,
particularly the retin, it
is important to use
eye patch over the
closed newborn's
eyes.
Skin breakdown &
fluctuation of
temperature is also
possible considering
that the infant has
delayed growth &
development &
ineffective
thermoregulation.

Ladewig et al.
Contemporary
Maternal-Newborn
Nursing Care 6th Ed.
p.758

After 4-8 hour nursing

intervention the infant
will be from injury as
evidence by:
Infant did not have
corneal irritation or
drainage, skin
breakdown or major
fluctuation in
temperature

INDEPENDENT
Cover the infant's
eyes with eye
patches while under
phototherapy lights
Make certain that
eyelids are closed
prior to applying eye
patches
Inspect eyes each
shift for conjunctivitis,
drainage & corneal
abrasions due to
irritation from eye
patches
Provide minimal
coverage -only on
genital area
Avoid use of oily
applications on the
skin
Reposition infant
every 2 hours
Monitor axillary
temperature

Protects retina from

damage due to high
integrity light
Prevents corneal
abrasions
Prevents or
facilitates prompt
treatment of purulent
conjunctivitis
Provides maximal
exposure, shielded
areas becomes more
jaundice, so
maximum exposure is
essential
Prevents superficial
burns on skin
Provides equal
exposure of all skin
area & prevents
pressure area
Hyethermia may
result from the
increased
environmental heat.
Additional heat from
phototherapy lights
frequently cause rise
in body temperature.
Fluctuations in
temperature may
occur in response to
radiation &
convection

After 4-8 hour of

nursing intervention,
goal is fully met, the
infant was free of
injury as evidenced
by:
Eyes are protected,
skin is intact, and
maintained a stable
temperature

Drug
Drug Name

Dosage & Route

Action

Indication

Contradiction

Adverse Effects

AMINOPHYLLIN
E (theophylline
ethylenediamide
)
(am-in-off'i-lin)

Child: IV Loading Dose 6

mg/kg IV over 30 min IV
Maintenance Dose 19 y, 1
mg/kg/h; >9 y, 0.75
mg/kg/h PO 19 y, 1 mg/kg/h
times 24 h in 4 divided
doses; >9 y, 0.75 mg/kg/h
times 24 h in 4 divided doses
Infant: PO/IV 611 mo, 0.87
g/kg/h; 26 mo, 0.5 mg/kg/h
Neonate: PO/IV 0.16
mg/kg/h
Neonatal Apnea
Neonate: PO/IV Loading
Dose 5 mg/kg PO/IV
Maintenance Dose 5
mg/kg/d divided q12h

Aminophylline is a
salt of theophylline
with effects similar
to those of other
xanthines (e.g.,
caffeine and
theobromine).
Action is dependent
on theophylline
content
(approximately
80%) and is
measured as
theophylline in the
serum.

To prevent
and relieve
symptoms of
acute
bronchial
asthma and
treatment of
bronchospasm
associated
with chronic
bronchitis and
emphysema.

Hypersensitivity
to xanthine
derivatives or to
ethylenediamine
component;
cardiac
arrhythmias.
Safety during
pregnancy
(category C) or
lactation is not
established.

CNS: Nervousness,
Assessment & Drug Effects
restlessness, depression,
insomnia, irritability,

Monitor for S&S of toxicity (generally related to

headache, dizziness,
theophylline serum levels over 20 mg/mL).
muscle hyperactivity,
Observe patients receiving parenteral drug
convulsions. CV: Cardiac
closely for signs of hypotension, arrhythmias,
arrhythmias, tachycardia
and convulsions until serum theophylline
(with rapid IV),
stabilizes within the therapeutic range.
hyperventilation, chest
pain, severe hypotension,

Note: High incidence of toxicity is associated

cardiac arrest. GI:
with rectal suppository use due to erratic rate of
Nausea, vomiting,
absorption.
anorexia, hematemesis,
diarrhea, epigastric pain.

Corophyllin ,
Paladron ,
Phyllocontin,
Somophyllin,
Somophyllin-DF,
Truphylline
Classifications:
BRONCHODILAT
OR
(RESPIRATORY
SMOOTH
MUSCLE
RELAXANT);
XANTHINE

Nursing Responsibility

Monitor & record vital signs and I&O. A sudden,

sharp, unexplained rise in heart rate may
indicate toxicity.

Lab tests: Monitor serum theophylline levels.

Note: Older adults, acutely ill, and patients with

severe respiratory problems, liver dysfunction,
or pulmonary edema are at greater risk of
toxicity due to reduced drug clearance.

Note: Children appear more susceptible to CNS

stimulating effects of xanthines (nervousness,
restlessness, insomnia, hyperactive reflexes,
twitching, convulsions). Dosage reduction may
be indicated.