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Nursing Care Plan for a premature infant

Nursing Care Plan for a premature infant

Ratings: (0)|Views: 20,412 |Likes:
These NCP are only some of the possible NCP's for a premature infant..
I only have few objective cues, so feel free to add some when you make your own NCP...
For the interventions i should have put a lot, heheh, but then again, i know you could just add those when you make your own NCP...
If you'll notice some discrepancies, tell me..
If you've got violent reactions,inform me..
I will understand, I'm just human, I also make mistakes... -^,^-
These NCP are only some of the possible NCP's for a premature infant..
I only have few objective cues, so feel free to add some when you make your own NCP...
For the interventions i should have put a lot, heheh, but then again, i know you could just add those when you make your own NCP...
If you'll notice some discrepancies, tell me..
If you've got violent reactions,inform me..
I will understand, I'm just human, I also make mistakes... -^,^-

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Published by: Villablanca Michelle on Sep 28, 2010
Copyright:Attribution Non-commercial

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06/24/2013

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NURSING CARE PLANAssessmentNursingDiagnosisNursingGoalNursingInterventionRationaleOutcomeCriteriaActualEvaluation
SUBJECTIVE:
Asverbalizedby the ptSO: “naana’y oxygennganakataod saiya.”
OBJECTIVE:-
dyspneanoted-RR=-rapid, equalchestexpansion
ImpairedGasexchanger/t
immaturepulmonaryfunctioningAfter 24hrsof nursingintervention:patient willbegraduallyweaned toroom air andbreathenormallywithoutsupplemental oxygen.
*INDEPENDENT:
1. Assess respiratorystatus, noting signs of respiratory distress(e.g., tachypnea, nasalflaring, grunting,retractions, rhonchi, orcrackles).2. Assess skin color fordev’t of cyanosis.3. Promote rest,minimize stimulation& energy expenditure.
*COLLABORATIVE:
1. Monitorlab/diagnostic studiesas appropriate.-Tachypnea indicatesrespiratory distress espwhen respi are>75cpm/min after thefirst 5 hours of life.Expiratory gruntingrepresents attempt tomaintain alveolarexpansion; nasal flaringis a compensatorymechanism to increasediameter of nares &increase Oxygen intake.-Lack of Oxygen willresult in cyanosis.-to decrease themetabolic rate & Oxygenconsumption.-Reveals & prevents anyfurther complications.After 24 hrs of thorough nsg.Intervention,patient wasable to breathenormallywithoutsupplementaloxygen.Goal met.Seen pt. lyingon bedwithout theoxyhood.
 
AssessmentNursingDiagnosisNursingGoalNursingInterventionRationaleOutcomeCriteriaActualEvaluation
SUBJECTIVE:
“Naa man tosiya’yhilanatgahapon, nyakaron walanaman.”, aspt. SOverbalized.
OBJECTIVE:T=
35 C-tachypnea
Ineffectivethermoregulation r/t
toprematurityasevidencedby poorflexion &lack of subcutaneous fat.After 24hrsof thoroughnursingintervention, pt willexhibitthermalhomeostasisappropriatefor age =36.5-37 C(axillary)
*INDEPENDENT:
1. Assess V/S (esp T)2. Place infant in awarmer, isolette,incubator, or open bedwith radiant warmer oropen crib whereininfant also hasappropriate clothing.3. Use heat lampsduring certainprocedures & warmobjects coming incontact with theinfants body such asclothing.
*COLLABORATIVE:
1. Provide oradminister meds asprescribed.-Hypothermiapredisposes infant tocold stress, utilization of nonrenewable brown fatstores. Hyperthermiacauses furtherrespiratory depressioninstead of increased RR,leading to apnea &reduced O2 uptake.-Maintain thermoneutralenvironment, helpsprevent cold stress.-Decreases heat loss tothe cooler environmentof the room.-Helps prevent seizuresassociated withhyperthermia andAfter 24 hoursof closemonitoring,infant was ableto establishnormothermiaand had
T=36.5 C.
Goal wasmet, leftpatient lyingon bedafebrile &with atemperatureappropriatefor age.

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