UNIVERSITY of the ASSUMPTION

Unisite Subdivision, Del Pilar, City of San Fernando, 2000 Pampanga, Philippines

COLLEGE OF NURSING
LEVEL II
RLE 109
NURSING CARE PLAN (Preterm Infant – Anemia of Prematurity)

Patient: Baby X Gender: Female Age:

Diagnosis: Date of Admission: March 7, 2022

Assessment Diagnosis Scientific Planning Interventions Rationale Evaluation

Explanation (Goal Setting)
Objective Cues: Ineffective tissue Untimely birth After 6-8 hours of 1. Check for pale skin, cyanosis, 1. Systemic vasoconstriction After 6-8 hours of
perfusion related to occurring before nursing intervention mottling, cool or clammy resulting from reduced nursing intervention
• 32 weeks old anemia as evidenced placental iron patient will be able to: skin. cardiac output may be the patient shall be
• Capillary refill by inadequate RBC transport and fetal manifested by diminished able to:
time (CRT) is production, pale skin, erythropoiesis are • Obtain vitals within skin perfusion and loss of
more than 3 apnea, tachycardia complete patient’s normal pulses.
seconds and fast heart beat range • Obtained vitals
• Cyanosis 2. Monitor V/S regularly. 2. VS are important components within patient’s
• pale skin • Acquire absence of Document findings. of patient care as they normal range
• Cool skin pale skin and establish baseline data and
temperature cyanosis indicates patient’s health • Acquired absence
• nails and hair Insufficient iron status. Deviations of V/S are of pale skin and
brittle stores • Capillary refill time maybe indicative of other cyanosis
• slow weight (CRT) of less than 3 problems that warrant
gain seconds. further investigations to rule • Capillary refill
• Fast or out complications. time (CRT) of less
difficult • Increase fluid than 3 seconds.
breathing intake through 3. Assess for optimal fluid 3. Sufficient fluid intake
Insufficient balance. Administer IV maintains adequate filling
• Apnea breastfeeding • Increased fluid
erythropoiesis after fluids as ordered. pressures and optimizes
• Difficulty with intake through
birth cardiac output needed for
oral feeding breastfeeding
tissue perfusion.
 UNIVERSITY of the ASSUMPTION
Unisite Subdivision, Del Pilar, City of San Fernando, 2000 Pampanga, Philippines

• Tachycardia • Decrease the 4. Monitor and note the urine 4. Kidneys that are not • Decreased the
anxiety of the output. perfusing adequately will not anxiety of the
V/S as follows: mother produce urine. Monitor for mother
T: 35.7C After 2-3 days of nursing urine output less than 30
BP: 30/60 mmHg Decrease in blood intervention patient will ml/hour or very dark, After 2-3 days of
HR: 172 bpm volume or RBC be able to: concentrated urine. nursing intervention
RR: 67bpm production patient shall be able to:
• Obtain balance
input and output. 5. Monitor intake, observe 5. Monitor intake, observe • Obtained balance
Laboratory test changes in urine output. changes in urine output. input and output.
Hemoglobin: 9 g/dL Anemia of • Maintain weight at Record urine specific gravity Record urine specific gravity
Hematocrit: 31% Prematurity a satisfactory level as necessary. as necessary. • Maintained
WBC: 10,500 f/l for height, age, and weight at a
Platelet count: gender. satisfactory level
245,000 f/l 6. Encourage the mother to 6. To increase the intake of for height, age,
• Maintain adequate engage breastfeeding breastfeeding milk for the and gender.
decrease in the peripheral nutrition of the baby.
cellular components perfusion as • Maintained
required for the evidenced by 7. Monitor hemoglobin 7. The lower the oxygen adequate
delivery of oxygen strong pedal frequently. saturation is, the lower is the peripheral
pulses, warm skin affinity for hemoglobin, perfusion as
temperature, and meaning oxygen uptake will evidenced by
intact skin without be reduced. That results in strong pedal
edema less oxygen circulating in the pulses, warm
Ineffective tissue
body. skin temperature,
perfusion related to
anemia as evidenced and intact skin
by inadequate RBC without edema
8. Provide formula fortified 8. For the improvement in the
production, pale
with iron, or iron level of red blood cells and
skin, apnea,
supplement. stored iron in their blood
tachycardia and fast
heart beat
 UNIVERSITY of the ASSUMPTION
Unisite Subdivision, Del Pilar, City of San Fernando, 2000 Pampanga, Philippines

Reference: 9. Provide supplements like 9. Those with anemia,

Anemia of prematurity vitamin E and folic acid as reticulocytotic, and oxygen
causes, symptoms, needed requirement may benefit
diagnosis, treatment & from additional vitamin E.
prognosis
(healthjade.net) 10. Provide oxygen as required 10. To acquire normal
temperature and promote
normal breathing.

Collaborative
11. Collaborative monitoring 11. Identify deficiencies and
laboratory test results. Give needs treatment / response
a complete red blood cells / to therapy
blood product packed as
indicated.

Submitted by: Catacutan, Jariel L.

BSN 2-B