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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

for devt of cyanosis. Lack of Oxygen will result in cyanosis.

3. Promoted rest, minimize stimulation & energy expenditure. To decrease the metabolic rate & Oxygen consumption. *COLLABORATIVE: 1. Monitored lab/diagnostic studies as appropriate. Reveals & prevents any further complications.

ASSESSMENT SUBJECTIVE:

SCIENTIFIC BASIS

Babies born before 34 weeks often can't feed Wala pa na siya'y from a bottle or breast kaon , as pt SO because they have stated.. trouble coordinating sucking, breathing, and swallowing. Also, newborns with breathing problems, OBJECTIVE: very low oxygen levels, gagging, -found patient lying on circulatory problems, bed supine with IV blood infection, or D5IMB 500 other illnesses might -small for gestational not be able to feed age. through a nipple (orally). Preterm babies lose more Nursing Diagnosis: water through the skin or respiratory tract Altered nutrition: less than babies born at than body full term. Also, 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. Such babies NPO status. can become dehydrated or

INTERVENTION WITH RATIONALE After 24hrs of INDEPENDENT: continuous nursing 1. Assessed presence intervention, pt will of reflexes associated demonstrate steady wt with feeding (i.e gain in a normal curve swallowing, sucking & (@ least 20-30g/day) coughing). and also maintained growth. Determines the appropriate feeding method for the infant. 2. Initiated intermittent or tube feedings as indicted. 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. 3. Positioned infant on right side or prone with HOB elevated @ 30 degrees.

PLAN OF CARE

EVALUATION After 24hrs,pt was seen beside mother, exhibiting good suckand-swallow reflex. Child will exhibit no further weight loss and, if malnourished, will gain 2.2 lb (1 kg) per week. Goal met.

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. Blood tests are also done to monitor electrolyte levels.

Facilitates gastric emptying & prevents reflux. COLLABORATIVE: 1. Feed as frequently as indicated based on infants weight & estimated stomach capacity. Infants <1250g are usually fed q 2hrs; infants b/w 1500 & 1800g are fed q 3hrs.

2. Administered supplemental vitamins & minerals, esp Vit A, B, C, D, & E and Iron as prescribed. Replaces low nutrient stores to promote adequate nutrition & reduce risk on infection

ASSESSMENT Subjective: N/A Objective: Gestational age of 33 weeks. Current weight: 1.85 kgs Neurological status: LOC: Lethargic Capillary refill time of 3 seconds. Integumentary Status: pale legs, Moderate pallor cool and dry skin neonate is placed in the isolation room Temperature: 35.5 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. In addition, because the infant does not flex the body well but remains in an extended position. Rapid cooling from 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

PLAN OF CARE 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 neonates body temperature at normal level. Pt. will have a and warm, dry skin

INTERVENTION WITH RATIONALE INDEPENDENT: Monitored the neonates body temperature until discharge To determine the need for intervention and the effectiveness of therapy.

EVALUATION 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 neonates body temperature at normal level. neonate has warm, dry skin

Dried the newborn thoroughly and quickly and discard the wet blanket. Place the infant under a pre warmed radiant warmer. Drying quickly and placing and placing

Nursing Diagnosis: Ineffective thermoregulation related to immaturity and lack of subcutaneous and brown fat.

also has limited amount of brown fat; special tissue present in newborns to maintain body temperature. Source: Maternal and Child Health Nursing, 4th Ed. By Pillitteri, p.741

on a warm, dry surface prevent heat loss from evaporation. Avoided placing infant on cold surface or using cold instrument in assessment. 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. Helps conserve heat in the body

2. parents will express understanding of neonates thermoregulatory disturbance and thermoregulation

2. parents expressed understanding of neonates thermoregulatory disturbance and thermoregulation

Teach the mother about the infants need for warmth and to keep the infants head covered The infants head provides a large surface area for heat loss

Taught 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 neonates health

ASSESSMENT Subjective: n/a since a potential diagnosis Objective: -patient is diagnosed with neonatal sepsis upon admission -RR; 58 cycles/min -HR: 148 bpm

SCIENTIFIC BASIS The newborns immune system is not fully activated until some time after birth. Limitation in the newborns inflammatory response result in failure to recognize, localize, and destroy invasive bacteria thus, increasing risk for infection.

PLAN OF CARE After 8 hours of nursing interventions the infant will not experience spread of infection as manifested by Infants 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 baby. 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, the goal is fully met. The infant did not experienced spread of infection as manifested by Infants HR remained <160 bpm RR was <60 cycles/ min

Nursing Diagnosis: Risk for infection r/t spread of pathogens secondary to identified

sepsis and immature immune system

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

equipment used for infant is sterile, scrupulously clean & disposable. 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

infant. The ill neonate has difficulty maintaining a stable temp.

(5) Assessed TPR & BP, auscultate breath sounds 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) Provided respiratory support (oxyhood)

Respiratory support may be needed during the acute phase of the infection to prevent additional physiological stress

(7) Feed infant as ordered. 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.

Notify care giver of abnormal findings Lab results provide information about the pathogen and infants response to illness and treatment

(9) Monitored infant for hypoglycemia, jaundice, development of thrush, or signs of bleeding. Assessments coagulationprovide information about the development of complications of infection: hypoglycemia, hyperbilirubenia, opportunistic infections, 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.

ASSESSMENT Subjective: N/A Objective: Patient is on phototherapy for 3 days Dry skin Patient in supine position Has no clothes on during phototherapy, only mittens, socks, and diapers. 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. Due to lack of adipose tissue, the pressure exerted by 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

PLAN OF CARE After 8 hours of nursing intervention 1. Patients 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. Pressure areas may develop if newborn lies in one position for an extended period of time.

EVALUATION After 8 hours of nursing intervention, goal is fully met. Patients 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. Patient may develop a maculopapular rash which is transient side effect of

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 newborns skin Lotions and ointments may cause skin to burn if applied to exposed areas during phototherapy.