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CUES/ DATA NURSING DIAGNOSIS
RATIONALE GOALS/ OBJECTIVES
NURSING INTERVENTIONS
RATIONALE EVALUATION
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%
Ineffective breathing pattern related to immature neurologic and delayed pulmonary development
A premature lung is structurally underdeveloped 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
After 30 minutes of nursing interventions, the infant will experience an effective breathing pattern as manifested by
- Infant’s RR is between 40 and 60
- Infant will experience no apnea
INDEPENDENT:(1) assess RR and pattern
(2) provide respiratory assistance as needed (oxygen hood)
(3) position infant on side with a rolled blanket behind his back
(4) provide tactile stimulation during periods of apnea
(1) assessment provides information about neonate’s ability to initiate and sustain an effective breathing pattern(2) assistance helps the newborn by clearing the airway and promoting oxygenation(3) lying on the side position facilitate breathing(4) stimulation of the sympathetic nervous
After 30 minutes of nursing interventions, goal is partially met, the infant experienced an effective breathing pattern as manifested by
- Infant’s RR was between 40 and 60
- Infant experienced less episodes of apnea
increase in the work of breathing.
SOURCE;Gelli’s and Kagan’s Current Pediatric Therapy by Burg Ingelfinger p. 261
system increases respiration
Delmar’s Maternal- Infant Nursing Care Plans 2nd edition by Karla Luxner p. 223
CUES/DATANURSING
DIAGNOSISRATIONALE
GOALS/EXPECTED OUTCOMES
NURSING INTERVENTION
RATIONALE EVALUATION
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
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
After 1 hour of nursing intervention, patient will maintain normal body temperature from 36.5-37.5
1. Staff members will take steps to maintain neonate’s body temperature at normal level. Pt. will have a and warm, dry skin
INDEPENDENT:
Monitor the neonate’s body temperature until discharge
Dry newborn thoroughly and quickly and discard the wet blanket. Place the infant
To determine the need for intervention and the effectiveness of therapy.
Drying quickly and placing and placing on a warm, dry surface prevent heat
After 1 hour of intervention, the goal is fully met. The neonate maintained a stable body temperature at 36 .7C evidenced by:
1. staff members kept neonate’s body temperature at normal level. neonate has warm, dry skin
seconds 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)
evaporation is likely to 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
2. parents will express understanding of neonate’s thermoregulatory
under a pre warmed radiant warmer.
Avoid placing infant on cold surface or using cold instrument in assessment.
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 infant’s need for warmth and to
loss from evaporation.
Cold surface and instrument increase heat loss by conduction
To prevent excessive cooling.
Helps conserve heat in the body
The infant’s head provides a large surface area for heat loss
2. parents expressed understanding of neonate’s thermoregulatory disturbance and
newborns to maintain body temperature.
Source: Maternal and Child Health Nursing, 4th Ed. By Pillitteri, p.741
disturbance and thermoregulation
keep the infant’s head covered
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
Careful teaching allows family members to take an active role in maintaining the neonate’s health.
Sources: Ladewig et al. Contemporary Maternal-Newborn Nursing care 6th ed. P645 Taylor Et.Al Nursing Diagnosis Reference Manual 6th Ed. pp. 525-526
thermoregulation
regulation
CUES/DATANURSING
DIAGNOSISRATIONALE
GOALS/EXPECTED OUTCOMES
NURSING INTERVENTION
RATIONALE EVALUATION
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 characteristics: loose, brown with
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
After 1 day of nursing intervention, the neonate will receive adequate fluid and nutrients for growth during hospitalization:
1. establish effective suck and swallow reflexes, allowing for adequate nutritional intake
INDEPENDENT:
Assess the neonates sucking pattern. Try to correct ineffective sucking pattern
Make sure the neonate’s tongue is properly positioned
To help eliminate ongoing difficulties
To enable the neonate to suck
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
tinge of green in color
Type of feeding: discontinuation of OGT, breastfed.
Poor muscle tone
pale conjunctivae
Pale mucous membrane
a diet than the mature infant does. Nutritional problems are compounded by the preterm infant’s immature reflexes, which makes swallowing and sucking difficult.
(Maternal & Child health Nursing, 4th Ed. By Pillitteri, p.739)
2. maintain good skin turgor, moist mucous membrane and flat , soft fontanels
under the nipple of the mother
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
adequately
To establish the need for immediate medical intervention
The neonate may temporary require an alternative means of obtaining adequate fluid and calories
2. maintained good skin turgor, moist mucous membrane and flat , soft fontanels
CUES/ DATA NURSING DIAGNOSIS
RATIONALE GOALS/ OBJECTIVES
NURSING INTERVENTION
S
RATIONALE EVALUATION
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
Risk for aspiration related to premature infant’s impaired sucking reflex
The anatomic
and functional immaturity of preterm infants elevate their risks for
minor and more significant complications, like aspiration in which entry of secretions, solids, or fluids into the trachea passages is high. All newborns have poor
After 2 hours of nursing interventions, the infant will not experience aspiration
- the infant will maintain clear breath sounds
INDEPENDENT:(1) elevate head of bed or place child in semi Fowler’s position, or position head of the baby upright
(2) observe for signs to stop feeding momentarily, such as elevated eyebrows, wrinkled forehead
(3) burp frequently because of excessive air
(1) semi fowler’s relaxes tension of the abdominal muscles, allowing for improved breathing
(2)to allow the infant to rest
(3) infants are particularly subject to
After 2 hours of nursing interventions, the infant did not experienced aspiration
- the infant maintained clear breath sounds
muscle tone of the cardiac sphincter of the esophagus, thus causing regurgitation. Newborn’s cough reflex is not well developed. Moreover, during the first few days of life, the newborn has increased mucus.
Source: Ladewig et al. Contemporary Maternal-Newborn Nursing care 6th ed. P 653
swallowing
(4) hold an infant with his head elevated during feeding and position her in an infant seat after feeding
(5)instruct the family members in the home care plan
accumulation of gas in the stomach while feeding, and this can cause considerable 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 Manual 6th edition by Ralph and Taylor pp. 394- 395
CUES/DATA NURSING DIAGNOSIS
RATIONALE GOALS and OBJECTIVES
NURSING INTERVENTIONS
RATIONALE EVLUATION
Subjective:
n/a since it is a potential diagnosis
Objective:
-10 days old-temperature: 36.2ºC-jaundiced skin- patient is in photo therapy for 4 days
Risk for injury related to use of 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 retina, it is important to use eye patch over the closed newborn’s eyes. Skin breakdown
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.
INDEPENDENT:(1)Cover baby’s 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
(1)Protects retina from damage due to high intensity light.
(2)Prevents corneal abrasions.
(3) Provides visual stimulation and facilitates attachment
After 8 hours of nursing interventions, the goal is fully met. Neonate was free of injury. The infant’s eyes are protected, skin is intact, and maintained a stable temperature.
- on breast-milk, OGT feeding-consumes five diapers/day-labs: increased bilibrubin levels
and fluctuation of temperature is also possible considering that the infant has delayed growth and development and ineffective thermoregulation.
Source: Ladewig et al. Contemporary Maternal-Newborn Nursing care 6th ed. P758
feeding.(4) Inspect eyes each shift for conjunctivitis, drainage and corneal abrasions due to irritation 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.
behaviors.(4)Prevents or facilitates prompt treatment of purulent conjunctivitis.
(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
(10) Place plexiglas shield between baby and light. Monitor baby’s skin and core temperature frequently until tmperature is stable.
(11) Check axillary temperature.
direct bilirubin levels or liver damage; may last for 2-4 months.(10)Hypothermia and 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 baby’s temperature. Fluctuations in temperature may occur
inresponse to radiation and convection.
CUES/ DATA NURSING DIAGNOSI
S
RATIONALE GOALS/ OBJECTIVES
NURSING INTERVENTION
S
RATIONALE EVALUATION
Subjective:
-n/a since a potential diagnosis
Objective:
- patient is diagnosed with neonatal sepsis upon admission
Risk for infection r/t spread of pathogens secondary to identified sepsis and immature immune system
The newborn’s immune system is not fully activated until some time after birth. Limitation in the newborn’s inflammatory response
After 8 hours of nursing interventions the infant will not experience spread of infection as manifested by
- Infant’s HR remains <160 bpm
- RR is <60 cycles/
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
(1) handwashing prevents the spread of pathogens coming from the infant to the caregiver and vice versa(2) this would prevent the spread of pathogens to the infant from equipment
After 8 hours of nursing interventions, the goal is fully met. The infant did not experienced spread of infection as manifested by
- Infant’s HR remained <160 bpm
- RR was
- -RR; 58 cycles/min
- HR: 148 bpm
- Labs:Increased WBC levels
result in failure to recognize, localize, and destroy invasive bacteria thus, increasing risk for infection.
Source: Ladewig et al. Contemporary Maternal-Newborn Nursing care 6th ed. P. 580
min clean & disposable. Do not share equipment with other infants
(3) place infant in isolette/ isolation room per hospital policy
(4) maintain neutral thermal environment
(5) assess TPR & BP, auscultate breath sounds
(3) placing the infant in an isolette allows close observation of the ill neonate & protects other infants from infection(4) a neutral thermal environment decreases the metabolic needs of the infant. The ill neonate has difficulty maintaining a stable temp.(5) assessments provide information about the spread of infection, increased RR and HR, decreased BP are signs of sepsis. Spread of infection may
<60 cycles/ min
(6) provide respiratory support (oxyhood)
(7) feed infant as ordered (OGT)
(8) monitor lab results as obtained. Notify care giver of abnormal findings
(9) monitor infant for
cause resp. distress(6) resp. support may be needed during the acute phase of the infection to prevent additional physiological stress(7)nutritional needs may 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 infant’s response to illness and treatment (9) assessments coagulationprovide information about the development of
hypoglycemia, jaundice, development of thrush, or signs of bleeding
DEPENDENT:
(10) administer IV fluids as ordered (D10IMB)(11) administer antibiotics as ordered
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.Delmar’s Maternal- Infant Nursing Care Plans 2nd edition by Karla Luxner p. 237
Cues Nursing Diagnosis
Rationale Goals and Objectives
Interventions Rationale Evaluation
Objective:
Patient is on phototherapy for 4 days
Consumes 5 diapers per day
Slightly jaundice in color
Dry skin
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
After 8 hours of nursing intervention
1. Patient’s skin will remain intact
No signs of skin
INDEPENDENT:
Patient position
After 8 hours of nursing intervention, goal is fully met. Patient’s skin remained intact as evidenced by:
No signs
Patient in supine position
Has no clothes on during phototherapy, only mittens, socks, and diapers
Has eye cover during phototherapy
bony prominences on the skin is greater thus increases the risk of skin breakdown.
Source: Ladewig et al. Contemporary Maternal-Newborn Nursing care 6th ed. P763
breakdown Change position every 2 hours
Monitor skin for rashes and bronzing every 8 hours.
Inspect perianal area after each diaper change for signs of breakdown
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.
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
of skin breakdown
Avoid using lotions or ointments on the newborn’s skin
skin breakdown.
Lotions and ointments may cause skin to burn if applied to exposed areas during phototherapy.
Source: Ladewig et al. Contemporary Maternal-Newborn Nursing care 6th ed. P759- 761
Diagnosis Plan/Goal Outcome Criteria Interventions Rationale Evaluation
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
Goals:
Long-term: Newborn will be able to sustain adequate/normal self thermoregulation.
Short-term: Provide assistance and support to maintain adequate/normal temperature
1. Infant’s body temperature will remain within normal axillary range, 36.5-37 degrees Celsius (Glass, 1999, p. 188).
2. Mother will verbalize possible methods of heat loss & demonstrate understanding of conduction, convection, radiation, & evaporation within 12 hours.
3. Mother will demonstrate maintenance of a neutral thermal environment within 24 hours.
4. Mother will demonstrate proper skin-to-skin warming technique prior t discharge.
1.Monitor axillary temperature at least every 8 hours; more frequently for infants at high risk.
2.Provide heat/warm the newborn using incubators, radiant warmer, swaddling, and skin-to-skin contact.
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.
1.Regular temperature monitoring will identify adequate or inadequate thermoregulation (Glass, 1999, p.188). Axillary temperature is good indicator of newborn’s surface temperature (Glass, 1999, p. 188).
2.To warm the newborn and adequately maintain accepted thermal range (Wong, 2003, p. 371).
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).
1. Newborn self maintains adequate body temperature for 24 hours prior to discharge.
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 demonstrates proper skin-to skin warming technique prior to discharge.