ASSESSMENT SUBJECTIVE: As verbalized by the pt SO: “nagalisod man ug ginhawa ang ako baby.

SCIENTIFIC BASIS Preterm infants have great difficulty initiating respirations at birth because pulmonary capillaries are still so immature. Lung surfactant does not form in adequate amounts until about 34th to 35th week of pregnancy. Inadequate lung surfactant leads to alveolar collapse with each expiration. This condition forces an infant to use maximum strength to inflate lung alveoli each time.

PLAN OF CARE After 8hrs of nursing intervention: patient will be able to meet the exact amount of oxygen needed.

INTERVENTION WITH RATIONALE INDEPENDENT: 1. Assessed respiratory status, noting signs of respiratory distress (e.g., tachypnea, nasal flaring, grunting, retractions, rhonchi, or crackles). ® Tachypnea indicates respiratory distress esp when respi are >75cpm/min after the first 5 hours of life. Expiratory grunting represents attempt to maintain alveolar expansion; nasal flaring is a compensatory mechanism to increase diameter of nares & increase Oxygen intake.

EVALUATION Goal met. As evidence by patient manifests normal sign of breathing. Oxygen Saturation 100% RR= 54

OBJECTIVE: - Dyspnea noted - RR= 64 -rapid, equal chest expansion Oxygen Saturation: 98% Nursing Diagnosis: Impaired Gas exchange r/t immature pulmonary functioning.

2. Assessed skin color

Monitored lab/diagnostic studies as appropriate. 3. Promoted rest. ® Reveals & prevents any further complications. ® To decrease the metabolic rate & Oxygen consumption. minimize stimulation & energy expenditure. .for dev’t of cyanosis. *COLLABORATIVE: 1. ® Lack of Oxygen will result in cyanosis.

2. and swallowing. trouble coordinating sucking. sucking & (@ least 20-30g/day) coughing). breathing. -found patient lying on circulatory problems. gagging.e gain in a normal curve swallowing. pt will of reflexes associated demonstrate steady wt with feeding (i. if malnourished. exhibiting good suckand-swallow reflex. as pt SO because they have stated. and also maintained growth. Also. Preterm babies lose more Nursing Diagnosis: water through the skin or respiratory tract Altered nutrition: less than babies born at than body full term.ASSESSMENT SUBJECTIVE: SCIENTIFIC BASIS Babies born before 34 weeks often can't feed “Wala pa na siya'y from a bottle or breast kaon ”.2 lb (1 kg) per week. Child will exhibit no further weight loss and. bed supine with IV blood infection. or D5IMB 500 other illnesses might -small for gestational not be able to feed age. OBJECTIVE: very low oxygen levels.. Initiated intermittent or tube feedings as indicted. Also. PLAN OF CARE EVALUATION After 24hrs. Goal met. the requirements r/t to kidneys in a small stomach premature baby have capacity & prematurity not grown enough to as evidenced by weak control water levels in feeding reflexes & the body. . ® Gavage feedings may be necessary to provide adequate nutrition in infant who has a poorly coordinated suck-andswallow reflex or who becomes fatigued during oral feedings. Assessed presence intervention. Such babies NPO status. newborns with breathing problems. through a nipple (orally). Positioned infant on right side or prone with HOB elevated @ 30 degrees. will gain 2. can become dehydrated or INTERVENTION WITH RATIONALE After 24hrs of INDEPENDENT: continuous nursing 1. ® Determines the appropriate feeding method for the was seen beside mother. 3.

C. ® Facilitates gastric emptying & prevents reflux. ® Infants <1250g are usually fed q 2hrs. ® Replaces low nutrient stores to promote adequate nutrition & reduce risk on infection . infants b/w 1500 & 1800g are fed q 3hrs. B. Blood tests are also done to monitor electrolyte levels.overhydrated. The NICU team keeps track of how much premature babies urinate (by weighing their diapers) to make sure that their fluid intake and urine output are balanced. Administered supplemental vitamins & minerals. Feed as frequently as indicated based on infant’s weight & estimated stomach capacity. D. & E and Iron as prescribed. COLLABORATIVE: 1. 2. esp Vit A.

ASSESSMENT Subjective: N/A Objective:  Gestational age of 33 weeks.85 kgs  Neurological status:  LOC: Lethargic  Capillary refill time of 3 seconds. dry skin INTERVENTION WITH RATIONALE INDEPENDENT:  Monitored the neonate’s body temperature until discharge ® To determine the need for intervention and the effectiveness of therapy. Moderate pallor  cool and dry skin  neonate is placed in the isolation room  Temperature: 35. because the infant does not flex the body well but remains in an extended position. dry skin Dried the newborn thoroughly and quickly and discard the wet blanket. The neonate maintained a stable body temperature at 36 .  Current weight: 1. Rapid cooling from evaporation is likely to occur.5-37.  Integumentary Status:  pale legs. the goal is fully met.5 1. EVALUATION After 1 hour of intervention. Place the infant under a pre warmed radiant warmer. Staff members will take steps to maintain neonate’s body temperature at normal level. neonate has warm. will have a and warm.7C evidenced by: 1. In addition. staff members kept neonate’s body temperature at normal level. The preterm infant PLAN OF CARE After 1 hour of nursing intervention. Pt.5 C  Baby is placed in an extended position  Poor muscle tone SCIENTIFIC BASIS 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. patient will maintain normal body temperature from 36. ® Drying quickly and placing and placing . 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.

Nursing Diagnosis: Ineffective thermoregulation related to immaturity and lack of subcutaneous and brown fat. 4th Ed. also has limited amount of brown fat. ® Cold surface and instrument increase heat loss by conduction  Provided Ambient temperature of the room where the newborn is kept should be monitored ® To prevent excessive cooling Mummified and used thick blankets to cover the patient. parents will express understanding of neonate’s thermoregulatory disturbance and thermoregulation 2. parents expressed understanding of neonate’s thermoregulatory disturbance and thermoregulation . ® Helps conserve heat in the body 2. By Pillitteri. p. dry surface prevent heat loss from evaporation. special tissue present in newborns to maintain body temperature. Source: Maternal and Child Health Nursing.741 on a warm. Avoided placing infant on cold surface or using cold instrument in assessment.

such as cool extremities. Importance of contacting a health care provider when problems related to temp regulation. Factors in home that contribute to neonatal heat loss and ways to minimize heat loss.Teach the mother about the infant’s need for warmth and to keep the infant’s head covered ® The infant’s head provides a large surface area for heat loss  Taught family members about: Signs and symptoms of altered body temperature. ® Careful teaching allows family members to take an .

58 cycles/min -HR: 148 bpm SCIENTIFIC BASIS The newborn’s immune system is not fully activated until some time after birth. ® hand washing prevents the spread of pathogens coming from the infant to the caregiver and vice versa (2) Ensure that all EVALUATION After 8 hours of nursing interventions. Limitation in the newborn’s inflammatory response result in failure to recognize. PLAN OF CARE 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 INTERVENTION WITH RATIONALE INDEPENDENT: (1) Ensured that all people coming in contact with infant wash their hands well before & after touching the role in maintaining the neonate’s health ASSESSMENT Subjective: n/a since a potential diagnosis Objective: -patient is diagnosed with neonatal sepsis upon admission -RR. the goal is fully met. localize. and destroy invasive bacteria thus. The infant did not experienced spread of infection as manifested by Infant’s HR remained <160 bpm RR was <60 cycles/ min Nursing Diagnosis: Risk for infection r/t spread of pathogens secondary to identified . increasing risk for infection.

scrupulously clean & disposable. P. Contemporary Maternal-Newborn Nursing care 6th ed. 580 equipment used for infant is sterile.sepsis and immature immune system Source: Ladewig et al. Do not share equipment with other infants ® This would prevent the spread of pathogens to the infant from equipment (3) Placed infant in isolate/ isolation room per hospital policy ® Placing the infant in an isolette allows close observation of the ill neonate & protects other infants from infection (4) Maintained neutral thermal environment ® A neutral thermal environment decreases the metabolic needs of the .

The ill neonate has difficulty maintaining a stable temp. Spread of infection may cause resp. increased RR and HR. decreased BP are signs of sepsis. (5) Assessed TPR & BP.infant. auscultate breath sounds ® Assessments provide information about the spread of infection. distress (6) Provided respiratory support (oxyhood) .

® 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) Monitored lab results as obtained.® Respiratory support may be needed during the acute phase of the infection to prevent additional physiological stress (7) Feed infant as ordered.

® Assessments coagulationprovide information about the development of complications of infection: hypoglycemia. hyperbilirubenia. development of thrush. jaundice. or signs of bleeding. opportunistic infections.Notify care giver of abnormal findings ® Lab results provide information about the pathogen and infant’s response to illness and treatment (9) Monitored infant for hypoglycemia. and coagulation deficits .

Collaborative: (10) administer IV fluids as ordered (D5IMB) -IV fluidsnhelp maintain fluid balance (11) administer antibiotics as ordered .antibiotics act to inhibit the growth of bacteria and destruction of bacteria. .

Patient’s skin will remain intact INTERVENTION WITH RATIONALE INDEPENDENT: Changed position every 2 hours ® Patient position changes will allow exposure of the phototherapy lights to all areas of the body that are uncovered. Patient’s skin remained intact as evidenced by:  No signs of skin breakdown No signs of skin breakdown Monitored skin for rashes and bronzing every 8 hours. Pressure areas may develop if newborn lies in one position for an extended period of time. Due to lack of adipose tissue. Nursing Diagnosis: Risk for Impaired skin integrity related to exposure to high intensity light secondary to phototherapy SCIENTIFIC BASIS The newborn lies in one position for a long period of time that may result in skin breakdown. P763 PLAN OF CARE After 8 hours of nursing intervention 1. the pressure exerted by bony prominences on the skin is greater thus increases the risk of skin breakdown. and diapers. Source: Ladewig et al. goal is fully met. ® Patient may develop a maculopapular rash which is transient side effect of . socks. only mittens. Contemporary Maternal-Newborn Nursing care 6th ed. EVALUATION After 8 hours of nursing intervention.ASSESSMENT Subjective: N/A Objective:  Patient is on phototherapy for 3 days  Dry skin  Patient in supine position  Has no clothes on during phototherapy.

phototherapy Inspected perianal area after each diaper change for signs of breakdown ® 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 Avoided using lotions or ointments on the newborn’s skin ® Lotions and ointments may cause skin to burn if applied to exposed areas during phototherapy. .