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prioritize NCP

prioritize NCP

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Published by zey young

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Published by: zey young on May 09, 2008
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08/29/2014

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C
UES/ DATA NURSINGDIAGNOSISRATIONALE GOALS/OBJECTIVESNURSINGINTERVENTIONSRATIONALE EVALUATION
Subjective:n/aObjective:
-
Preterm birth(34 wks and2days)
-
With Oxygenhoodregulated at10 liters per minute
-
RR:58 cycles/min
-
Episodes of apnea (6- 10secs)
-
O2 saturationof 91%Ineffectivebreathingpatternrelated toimmatureneurologicand delayedpulmonarydevelopmentA prematurelung isstructurallyunderdeveloped for postnatallife. To add, theprematuredelivery andthe inadequatepulmonarysurfactant. Adeficiency insurfactant,which functionsto decreasethe surfacetension withinthe alveoli.Withoutsurfactant, theinfantexperiencesdiffuseatelectasis,decreasedpulmonarycompliance,ventilationperfusionmismatching,and significantAfter 30 minutesof nursinginterventions, theinfant willexperience aneffectivebreathing patternas manifested by 
-
Infant’s RRis between40 and 60
-
Infant willexperienceno apneaINDEPENDENT:(1) assess RRand pattern(2) providerespiratoryassistance asneeded (oxygenhood) (3) position infanton side with arolled blanketbehind his back(4) provide tactilestimulation duringperiods of apnea(1)assessmentprovidesinformationaboutneonate’sability toinitiate andsustain aneffectivebreathingpattern(2)assistancehelps thenewborn byclearing theairway andpromotingoxygenation(3) lying onthe sidepositionfacilitatebreathing(4)stimulationof thesympatheticnervousAfter 30 minutesof nursinginterventions,goal is partiallymet, the infantexperienced aneffectivebreathing patternas manifested by 
-
Infant’sRR wasbetween40 and 60
-
Infantexperienced lessepisodesof apnea
 
increase in thework of breathing.SOURCE;Gelli’s andKagan’sCurrentPediatricTherapy byBurgIngelfinger p.261systemincreasesrespirationDelmar’sMaternal-InfantNursingCare Plans2
nd
edition byKarla Luxner p. 223
 
CUES/DATANURSINGDIAGNOSISRATIONALEGOALS/EXPECTEDOUTCOMESNURSINGINTERVENTIONRATIONALE EVALUATION Subjective:
N/A
Objective:
Gestationalage of 34weeks 2/7
Currentweight: 2.0kgs
Neurologicalstatus:
LOC:Lethargic
Capillary refilltime of 3seconds.
IntegumentaryStatus:
pale legs,Moderatepallor 
cool and dryskin
Turgor: lessthan 3Ineffectivethermoregulationrelated toimmaturity andlack of subcutaneousand brown fat The pretermnewborn hasa great dealof difficultyattaining bodytemperaturebecause shehas arelativelylarge surfacearea per kilogram of body weight.In addition,because theinfant doesnot flex thebody well butremains in anextendedposition.Rapid coolingfromevaporation islikely toAfter 1 hour of nursing intervention,patient will maintainnormal bodytemperature from36.5-37.5
1.
Staff memberswill take stepsto maintainneonate’sbodytemperature atnormal level.Pt. will have aand warm, dryskin INDEPENDENT:
Monitor theneonate’sbodytemperatureuntil discharge
Dry newbornthoroughlyand quicklyand discardthe wetblanket.Place theinfant under a
Todeterminethe needfor intervention and theeffectiveness of therapy.
Dryingquicklyandplacingandplacing ona warm,dryAfter 1 hour of intervention, thegoal is fully met.The neonatemaintained astable bodytemperature at36 .7Cevidenced by:
1.
staff memberskeptneonate’sbodytemperatureat normallevel.neonate haswarm, dryskin

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