MECONIUM ASPIRATION SYNDROME

ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

After 8 hours INDEPENDENT After 8 hours of
OBJECTIVE: Ineffective of nursing  Assess for signs of nursing
 Altered skin tissue intervention decreased tissue  Particular clusters of intervention the
characteristics. perfusion the patient perfusion. signs and symptoms patient was
(poor skin related to will be able occur with differing able to maintain
turgor) impaired to maintain causes. Evaluation of maximum
 Skin color: transport of maximum Ineffective Tissue tissue perfusion
pale oxygen tissue Perfusion defining to vital organs,
 Weak pulse perfusion to characteristics provides as evidenced by
 Presence of vital organs, a baseline for future warm and dry
bruits as evidenced comparison. skin, present
 Presence of by warm and and strong
edema dry skin,  Assess for probable  early detection of the peripheral
 Capilliary refill present and contributing factors source facilitates quick, pulses, vitals
test >3 strong related to temporarily effective management within patient’s
seconds peripheral impaired arterial normal range,
pulses, vitals blood flow. Some balanced I&O,
within examples include absence edema.
patient’s compartment
normal syndrome,
range, constricting cast,
balanced embolism, indwelling
I&O, absence arterial catheters,
edema. positioning,
thrombus, and
vasospasm.

 Check respirations and  Cardiac pump malfunction

absence of work of and/or ischemic pain may
breathing. result in respiratory
distress. Nevertheless,
MECONIUM ASPIRATION SYNDROME

abrupt or continuous
dyspnea may signify
thromboembolic pulmonary
complications.

 Examine GI function,
noting anorexia,  Decreased blood flow to
decreased or absent mesentery can turn out to
bowel sounds, nausea GI dysfunction, loss of
or vomiting peristalsis

 use pulse oximetry to  pulse oximetry is a useful

monitor oxygen tool to detect changes in
saturation and pulse oxygenation.
rate.
 Check Hgb levels  Low levels reduce the
uptake of oxygen at the
alveolar-capillary
membrane and
oxygen delivery to the
tissues.
 Check for pallor,  Nonexistence of peripheral
cyanosis, mottling, cool pulses must be reported or
or clammy skin. Assess managed immediately.
quality of every pulse. Systemic vasoconstriction
resulting from reduced
cardiac output may be
manifested by diminished
skin perfusion and loss of
pulses. Therefore,
assessment is required for
MECONIUM ASPIRATION SYNDROME

 Note skin texture and  Thin, shiny, dry skin with
the presence of hair,
ulcers, or gangrenous
areas on the legs or
feet.
 Reduced intake or
 Monitor intake, observe
changes in urine output.
Record urine specific
gravity as necessary.
constant comparisons
hair loss; brittle nails; and
gangrene or ulcerations on
toes and anterior surfaces
of feet are seen in patients
with arterial insufficiency. If
ulcerations are on the side
of the leg, they are usually
venous
unrelenting nausea may
consequence in lowered
circulating volume, which
negatively affects perfusion
and organ function.
Hydration status and renal
function are revealed by
specific gravity
measurements.

DEPENDENT

 Check for optimal  Sufficient fluid intake

fluid balance. maintains adequate
Administer IV fluids as filling pressures and
ordered. optimizes cardiac output
needed for tissue
perfusion.
 Administer phenytoin a  These reduce risk
s needed. of seizure.
MECONIUM ASPIRATION SYNDROME