SILLIMAN UNIVERSITY

COLLEGE OF NURSING
DUMAGUETE CITY

NURSING CARE PLAN ON

RISK FOR IMPAIRED FETAL GAS EXCHANGED
RELATED TO ALTERED BLOOD TO THE
PLACENTA AND FETUS

Submitted to:
Asst. Prof. Ida Olga Vidal

Submitted by:
Daisyree Y. Lui
BSN II-D

Date:
January 30,2020
 SILLIMAN UNIVERSITY
COLLEGE OF NURSING
DUMAGUETE CITY
Vision:
A leading Christian institution committed to total human development for the well-being of society and environment.

Mission:
1. Infuse into the academic learning the Christian faith anchored on the gospel of Jesus Christ; provide an environment where Christian fellowship and
relationship can be nurtured and promoted.
2. Provide opportunities for growth and excellence in every dimension of the University life in order to strengthen character, competence and faith.
3. Instill in all members of the University community an enlightened social consciousness and a deep sense of justice and compassion.
4. Promote unity among peoples and contribute to national development.

Goal:
Silliman aims to have…
● a quality and diverse body of students;
● a holistic and responsive educational program with a Christian orientation;
● a quality faculty comparable to Asian standards;
● a quality support staff;
● adequate facilities and administrative systems;
● a supportive and involved alumni; and a long-term financial viability.
 NURSING CARE PLAN ON RISK FOR IMPAIRED GAS EXCHANGED R/T ALTERED BLOOD FLOW FROM PLACENTA & FETUS

CUES/EVIDENCES: NURSING OBJECTIVES: INTERVENTIONS: RATIONALE: EVALUATION:

DIAGNOSIS:
Subjective: Risk for impaired • After an 8 hour Independent:
gas exchange r/t intervention,
Objective: altered blood flow the parents will
• Cord is to the placenta & be able to
protruding, fetus. successfully:
visible, and a. Demonstrate on • Educate and • This teaches • The parents are
palpable on the use of demonstrate the parents parents on the able to
mother’s vagina. apnea monitor on the use of apnea presence of successfully
• FHT were to inform them monitor. periods of demonstrate
variable of the infant’s apnea to avoid how to use the
decelerations responses in hypoxia in apnea monitor.
• FHR 90 bpm respiration and newborn.
• Delivered heart rate.
through CS
• APGAR score • The newborn
of 6 : will display
-A:1 improved gas
-P:2 exchanged and
-G:1 ABG levels as
-A:1 evidenced by:
-R:1 a. RR will be • Assess RR (frequency, • This reveals • RR-32 bpm,
within normal depth, and ease; any respiratory regular and
range (30- periods of apnea) effort, rate, and slow cries.
60bpm) depth which
affects the
amount of air
that reaches the
lungs of the
infant.
b. Infant’s skin • Assess infant for skin • Impaired gas • Infant’s skin
appearance will color and perfusion exchanged can color is pink
improve. cause tissue and absence of
(pinkish color) hypoxia which perfusion.
leads to poor
tissue perfusion
resulting to
changes in the
skin color.
c. Infant’s • Assess for changes in • Low oxygen • Minimal
response to consciousness(presence levels can result response to
stimulation will of irritability and to decreased in stimulation.
increase. somnolence) blood pressure (crying)
and impair
oxygenation in
the brain.
 • Monitors the
• Monitor ABG levels respiratory • ABG levels and
d. ABG levels and and O2 saturation function of the O2 saturation
O2 saturation newborn which are within
are within can detect normal range
normal range abnormal and stable.
ventilatory
drive.

• Reveals the
• Monitor chest x-ray presence of • The x-ray
studies for further respiratory shows no
evaluation. infection. respiratory
infection.
Collaborative: • Continuous
• Administer continuous positive airway • CPAP has
nasal airflow or CPAP pressure is improved
via nasal mask or face administered in infant’s airway
mask. cases of apnea
that can r/t
collapse of the
airway.
 • Administer • This drug • The drug aided
methylxanthines if stimulated in stimulating
indicated by physician spontaneous the infant’s
respiration respiratory
function.

References:

Silbert-Flagg, J., Pillitteri, A., & Pillitteri, A. (2018). Maternal & child health nursing: Care of the childbearing & childrearing family. Philadelphia:
Wolters Kluwer.

Wayne, G., By, -, Wayne, G., & Gil Wayne graduated in 2008 with a bachelor of science in nursing. He earned his license to practice as a registered
nurse during the same year. His drive for educating people stemmed from working as a community health nurse. He conducted first aid traini. (2019,
June 01). 10 Cesarean Birth Nursing Care Plans. Retrieved January 29, 2021, from https://nurseslabs.com/cesarean-birth-nursing-care-plans/7/