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/DATA NURSING DIAGNOSIS RATIONALE GOALS/EXPECTED

OUTCOMESNURSING

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 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

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 under a pre warmed

 

To determine the need for intervention and the effectiveness of therapy.

Drying quickly and placing and placing on a warm, dry surface prevent heat loss from

 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

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.

2. parents will express understanding of neonate’s thermoregulatory disturbance and thermoregulation

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 keep the infant’s head covered

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 thermoregulation

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 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

CUES/DATA NURSING DIAGNOSIS RATIONALE GOALS/EXPECTED

OUTCOMESNURSING

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 tinge of green in color

Type of feeding:

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

 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 under the nipple of the mother

 

To help eliminate ongoing difficulties

To enable the neonate to suck adequately

  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

discontinuation of OGT, breastfed.

Poor muscle tone

pale conjunctivae

Pale mucous membrane

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

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

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 INTERVENTIONS

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 muscle tone of the cardiac sphincter of the

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 swallowing

(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 accumulation of gas in the stomach while feeding, and this can

After 2 hours of nursing interventions, the infant did not experienced aspiration

- the infant maintained clear breath sounds

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

(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

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- on breast-milk, OGT feeding-consumes five

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 and fluctuation of temperature is also possible considering that the infant has

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 feeding.(4) Inspect eyes each shift for conjunctivitis, drainage and

(1)Protects retina from damage due to high intensity light.

(2)Prevents corneal abrasions.

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

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.

diapers/day-labs: increased bilibrubin levels

delayed growth and development and ineffective thermoregulation.

Source: Ladewig et al. Contemporary Maternal-Newborn Nursing care 6th ed. P758

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.

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 direct bilirubin levels or liver damage; may last for 2-4 months.

(10) Place plexiglas shield between baby and light. Monitor baby’s skin and core temperature frequently until tmperature is stable.

(11) Check axillary temperature.

(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 DIAGNOSIS

RATIONALE GOALS/ OBJECTIVES

NURSING INTERVENTIONS

RATIONALE EVALUATION

Subjective:

-n/a since a potential diagnosis

Objective:

- patient is diagnosed with neonatal sepsis upon admission

- -RR; 58 cycles/min

- HR: 148 bpm

- Labs:Increased WBC levels

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 result in failure to recognize, localize, and destroy invasive bacteria thus, increasing risk for

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/ min

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

(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

(3) placing the infant in an isolette allows close observation of the ill neonate &

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 <60 cycles/ min

infection.

Source: Ladewig et al. Contemporary Maternal-Newborn Nursing care 6th ed. P. 580

(4) maintain neutral thermal environment

(5) assess TPR & BP, auscultate breath sounds

(6) provide respiratory support (oxyhood)

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 cause resp. distress(6) resp. support may be needed during the acute phase of the infection to prevent additional physiological stress

(7) feed infant as ordered (OGT)

(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)

(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 complications of infection: hypoglycemia, hyperbilirubenia, opportunistic infections, and coagulation deficits(10) IV fluidsnhelp maintain fluid

(11) administer antibiotics as ordered

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 Patient in

supine position

Has no clothes on during phototherapy, only mittens, socks, and diapers

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.

After 8 hours of nursing intervention

1. Patient’s skin will remain intact

No signs of skin breakdown

INDEPENDENT:

Change position every 2 hours

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

After 8 hours of nursing intervention, goal is fully met. Patient’s skin remained intact as evidenced by:

No signs of skin breakdown

Has eye cover during phototherapy

Source: Ladewig et al. Contemporary Maternal-Newborn 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

Avoid using lotions or ointments on the newborn’s skin

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 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