NURSING CARE PLAN

Assessment . Nursing Diagnosis Scientific Basis Goals/Objectives Nursing Rationale Evaluation

SUBJECTIVE DATA: IMPAIRED GAS With deficient After 1-2 hour of INDEPENDENT • Tachypnea Goal Partially Met
N/A EXCHANGE related surfactant, areas nursing interventions, • Assess respiratory indicatea respiratory After 1-2 hour of
to immaturity of hypo inflation begin to the neonate will be status, noting signs of distress esp when RR nursing intervention
OBJECTIVE DATA: • newborn's lungs and occur & pulmonary able to improve respiratory distress is >75cpm after the the infant ventilation
Newborn Preterm 29 lack of surfactant resistance increase. ventilation as (tachypnea, dsypnea, first hour of life. improved as
weeks Age of The lungs are poorly evidenced by: grunting, retractions) Expiratory grunting evidenced by:
Gestation perfused, affecting • infant's skin • Assess skin color represents attempt to • Infant skin is pinkish
• Birth weight: 1060 gas exchange. becomes pinkish in for development of maintain alveolar in color
grams • Apgar Score: color cyanosis expansion, nasal • RR of 60-70cpm
4-intubated Because surfactant • respiratory rate of • Promote rest, flaring is a • infant was extubated
• Vital Signs: T- 35 does not form until 40-60cpm minimize stimulation compensatory and weaned to nasal
°C-35.5 °C HR- 130- the 34th week of • infant will be & energy expenditure mechanism to CPAP
150bpm RR- 70- gestation, as many as extubated and increaaw diameter of
80cpm 30% of low birth weaned to nasal COLLABORATIVE • nares & increase
• Dyspnea noted weight infants and as CPAP support Monitor laboratory/ oxygen intake.
• Expiratory grunting many as 50% of very diagnostic status as • Lack of oxygenation
and nasal flaring low birth weights appropriatea will result in cyanosis
noted infant are susceptible. • To decrease the
• Skin pale to cyanotic metabolic rate &
in color Source: Maternal & Child oxygen consumption
Health Nursing) • Laboratory results
reveals & prevents
Laboratory Studies any further
• Chest X-ray - hazy complications
appearance (See
table)
• BGA - Respiratory
Acidosis (See table)
 NURSING CARE PLAN

Assessment . Nursing Diagnosis Scientific Basis Goals/Objectives Nursing Rationale Evaluation

SUBJECTIVE DATA: INEFFECTIVE A premature lung is After 1-5 hour of INDEPENDENT • Assessment After 1-5 hour of
N/A BREATHING structurally nursing intervention , • Assess respiratory provides information nursing intervention,
PATTERN related to underdeveloped for the infant experience rate & pattern about the neonate's goal is fully met, the
OBJECTIVE DATE: immature neurologic postnatal life. To add, effective breathing • Provide tactile ability to initiate & infant experienced an
• Preterm 29 weeks & delayed pulmonary the premature pattern as evidenced stimulation during sustain an effective effective breathing
• Tachypnea noted development delivery & the by: periods of apnea breathing pattern pattern as manifested
RR 70-80cpm inadequate • RR will be between • Position infant on • Stimulation of the by:
• Episodes of apnea pulmonary surfactant. normal range 40- side sympathetic nervous • RR is between
• O2 saturation 85- A deficiency in 60cpm system increases normal range 55-
90% surfactant, which • shows no episodes DEPENDENT respiration 60cpm
functions to decrease of apnea • Provide respiratory • Lying on the side • shows no episode of
the surface tension assistance as needed position facilitates apnea
within the alveoli. as per Doctor's order breathing
Without surfactant the (See table) • Assistance helps the
infant experience newborn by clearing
diffuse atelectasis, the airway &
decreased pulmonary promoting
compliance, oxygenation
ventilation, perfusion,
mismatching &
significant in the work
of breathing.

Source: Gelli's & Kagan's

Current Pediatric Therapy
by Burg Ingelfinger
p.261
 NURSING CARE PLAN

Assessment . Nursing Diagnosis Scientific Basis Goals/Objectives Nursing Rationale Evaluation

SUBJECTIVE DATA: INEFFECTIVE The preterm newborn After 1-2 hour of INDEPENDENT • • To determine the After 1-2 hour of
N/A THERMOREGULATI has a great deal of nursing intervention, Monitor the neonate's need for intervention nursing intervention,
ON related immaturity difficulty attaining the infant will body temperature & the effectiveness of goal is fully met, the
OBJECTIVE DATE: and lack of body temperature maintain normal body • Place the infant therapy infant shows a stable
• Preterm 29 weeks subcutaneous & because it has a temperature as under pre warmed • Drying quickly & body temperature as
• Weight: 1060 grams brown fat relatively large evidence by: radiant warmer and placing on warm, dry evidenced by:
• LOC: Lethargic surface area per • Temperature of dry thoroughly & surface prevent heat
• Capillary refill time kilogram of body 36.5 °C-37.5 °C • quickly loss from evaporation • Body temperature of
of 3 seconds weight. In addition, Warm & dry skin • Avoid placing infant • Cold surface & 36.7 °C
• Intergumentary because the infant on cold surface or instrument increase • Infant has warm &
Status: - Pale legs, does not flex the body using cold instrument heat loss by dry skin
moderate pallor - well but remains in an in assessment conduction
Cool & dry skin - extended position. • Incubator/Isolette • Helps conserve
Turgor less than 3 Rapid cooling from temperature should heat in the body
seconds evaporation is likely be kept monitored
to occur.
The preterm infant
has little
subcutaneous fat for
insulation & poor
muscular
development does
not allow the child to
move actively as the
older infant does to
promote heat. The
preterm infant also
has limited amount of
brown fat; special
tissue present in
newborns to maintain
body temperature.

Maternal & Child Health

Nursing 4th Ed. By Pilliteri
p.741
 NURSING CARE PLAN

Assessment . Nursing Diagnosis Scientific Basis Goals/Objectives Nursing Rationale Evaluation

SUBJECTIVE DATA: RISK FOR INJURY Phototherapy After 4-8 hour nursing INDEPENDENT • Protects retina from After 4-8 hour of
N/A related to exposes the newborn intervention the infant • Cover the infant's damage due to high nursing intervention,
Phototherapy light to high intensity light. will be from injury as eyes with eye integrity light goal is fully met, the
OBJECTIVE DATA: Because it is not evidence by: patches while under • Prevents corneal infant was free of
• 1 day old male • known if phototherapy phototherapy lights abrasions injury as evidenced
Skin jaundice in color injures the delicate • Infant did not have • Make certain that • Prevents or by:
• Exposed on double structure of the eye, corneal irritation or eyelids are closed facilitates prompt • Eyes are protected,
phototherapy particularly the retin, it drainage, skin prior to applying eye treatment of purulent skin is intact, and
• Body Temp: 36.7 is important to use breakdown or major patches conjunctivitis maintained a stable
°C-37 °C eye patch over the fluctuation in • Inspect eyes each • Provides maximal temperature
closed newborn's temperature shift for conjunctivitis, exposure, shielded
Laboratory: eyes. drainage & corneal areas becomes more
• High Bilirubin level abrasions due to jaundice, so
after 24 hours of age Skin breakdown & irritation from eye maximum exposure is
151.8 umol/L (See fluctuation of patches essential
table) temperature is also • Provide minimal • Prevents superficial
possible considering coverage -only on burns on skin •
that the infant has genital area Provides equal
delayed growth & • Avoid use of oily exposure of all skin
development & applications on the area & prevents
ineffective skin pressure area
thermoregulation. • Reposition infant • Hyethermia may
every 2 hours result from the
• Monitor axillary increased
Ladewig et al. temperature environmental heat.
Contemporary Maternal- Additional heat from
Newborn Nursing Care 6th phototherapy lights
Ed. p.758
frequently cause rise
in body temperature.
Fluctuations in
temperature may
occur in response to
radiation &
convection
 Drug
Drug Name Dosage & Route Action Indication Contradiction Adverse Effects Nursing Responsibility

AMINOPHYLLIN Child: IV Loading Dose 6 CNS: Nervousness,

E (theophylline mg/kg IV over 30 min IV restlessness, depression,
Aminophylline is a To prevent Hypersensitivity Assessment & Drug Effects
ethylenediamide) Maintenance Dose 1–9 y, 1 insomnia, irritability,
salt of theophylline and relieve to xanthine
(am-in-off'i-lin) mg/kg/h; >9 y, 0.75 headache, dizziness,
with effects similar symptoms of derivatives or to
mg/kg/h PO 1–9 y, 1 acute muscle hyperactivity,  Monitor for S&S of toxicity (generally related
to those of other ethylenediamine
Corophyllin , mg/kg/h times 24 h in 4 bronchial convulsions. CV: Cardiac to theophylline serum levels over 20 mg/mL).
xanthines (e.g., component;
Paladron , divided doses; >9 y, 0.75 asthma and arrhythmias, tachycardia Observe patients receiving parenteral drug
caffeine and cardiac
Phyllocontin, mg/kg/h times 24 h in 4 treatment of (with rapid IV), closely for signs of hypotension, arrhythmias,
theobromine). arrhythmias.
Somophyllin, divided doses bronchospasm hyperventilation, chest and convulsions until serum theophylline
Action is dependent Safety during
Somophyllin-DF, Infant: PO/IV 6–11 mo, 0.87 associated pain, severe hypotension, stabilizes within the therapeutic range.
on theophylline pregnancy
Truphylline g/kg/h; 2–6 mo, 0.5 mg/kg/h with chronic cardiac arrest. GI:  Note: High incidence of toxicity is associated
content (category C) or
Neonate: PO/IV 0.16 bronchitis and Nausea, vomiting, with rectal suppository use due to erratic rate of
(approximately lactation is not
mg/kg/h emphysema. anorexia, hematemesis, absorption.
Classifications: 80%) and is established.
Neonatal Apnea diarrhea, epigastric pain.  Monitor & record vital signs and I&O. A
BRONCHODILAT measured as
Neonate: PO/IV Loading sudden, sharp, unexplained rise in heart rate
OR theophylline in the
Dose 5 mg/kg PO/IV may indicate toxicity.
(RESPIRATORY serum.
Maintenance Dose 5  Lab tests: Monitor serum theophylline levels.
SMOOTH mg/kg/d divided q12h  Note: Older adults, acutely ill, and patients
MUSCLE
with severe respiratory problems, liver
RELAXANT);
dysfunction, or pulmonary edema are at greater
XANTHINE
risk of toxicity due to reduced drug clearance.
 Note: Children appear more susceptible to
CNS stimulating effects of xanthines
(nervousness, restlessness, insomnia,
hyperactive reflexes, twitching, convulsions).
Dosage reduction may be indicated.