Nursing Care Plan

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Medical Diagnoses: Ineffective breathing pattern r/t inadequate pulmonary development, Ineffective thermoregulation and Ineffective infant feeding pattern

1. Ineffective breathing pattern r/t inadequate pulmonary development secondary to prematurity aeb opacities in bilateral lungs shown on x-ray suggesting surfactant deficiency disease, patient born at 22 5/7 weeks gestation. Data: patient on endotracheal ventilation Patient 02 sats often below 85 r/t # 2, 7

2. Ineffective thermoregulation r/t lack of subcutaneous fat secondary to prematurity aeb low birth weight and lack of subcutaneous fat stores, gestational age 22 weeks, current weight 0.640kg.

Data: increased WBC poor muscle tone, baby in isolette increased respiratory rate, immaturity r/t # 1,3,5,7

3. Imbalanced nutrition, less than body requirements r/t absent sucking reflex secondary to preterm birth aeb TPN. Data: Patient on TPN. 10/18 change to continuous feeds at 2.5mL/hr pale mucous membranes inability to ingest food poor muscle tone, body weight 20 percent or more below ideal r/t # 4,5,7

4. Risk for infection r/t immature body systems secondary to prematurity aeb baby born at 24 weeks, increased WBC count. Data: WBC 10/18 23.29 immature immunity visitors frequent r/t # 1,2,3,7,8

Demographics: 22 5/7 week gestational age, female delivered via vaginal birth on 10/1, 17 days old Admitting dx: premature birth Assessments: Monitor respiratory status Monitor heart, lung sounds Monitor vital signs Monitor ABGs Monitor intake/output, fluid balance Assess skin turgor Monitor lab values

5. Ineffective infant feeding pattern r/t inability to suck secondary to prematurity aeb TPN feedings. Data: Patient on TPN. 10/18 change to continuous feeds at 2.5mL/hr inability to coordinate sucking, swallowing, and breathing prematurity inability to initiate or sustain suck r/t # 3,7

6. Nursing dx: Risk for impaired parent, infant attachment r/t premature birth aeb separation, lack of privacy, baby born at 24 weeks, and physical barriers. Data: Nurse stated mother hesitant to hold, just held one time since birth little privacy when visiting r/t # 7

7. Risk for delayed growth and development r/t prematurity aeb birth at gestational age 22 5/7 weeks. Data: pt premature TPN, inability to ingest r/t # 2,3,4,5,6/p>

8. Risk for sudden infant death syndrome r/t prematurity aeb nonmodifiable seasonality risk factor and low birth weight. Data: infant under 1 year of age low birth weight prematurity SIDS higher in winter and fall months r/t # 4,7

NANDA Diagnostic Statement: 1. Ineffective breathing pattern r/t inadequte pulmonary development secondary to prematurity aeb opacities in bilateral lungs shown on x-ray suggesting surfactant deficiency disease, patient born at 22 5/7 weeks gestation.

Behavioral Outcome / Goal: Patient will maintain PO2/PCO2 levels within normal limits daily while in NICU until discharge date. Patient will suffer minimal respiratory distress and show increased respiratory function as evidenced by ABGs and breathing pattern until discharge date.

Nursing Interventions:

1.Take vital signs every 4 hours including apical pulse. Check lung, heart, and breath sounds every 4 hours.

2. Monitor laboratory studies (ABGs, serum glucose, electrolytes, cultures)

3. Institute continuous respiratory and cardiac monitoring (

4. Position infant on abdomen or in supine position with rolled diaper beneath shoulders to produce slight hyperextension (

5. Perform nursing actions to maintain airway clearance including suctioning.

6. Administer medications as indicated.

7. Encourage interaction with infant, visitation, and involve parent in caring for child.

8. Educate parents and family about the NICU including touring the NICU and introducing to staff members.

9. Explain the purpose of needles, tubes, and procedures (Board & Wenger 2003).


1. Permits monitoring of cardiovascular response to illness state and therapy. Essential monitoring for fluid collection in lungs and cardiac overload due to edema (Newfield, Hinz, Tilley, Sridaromont, &Maramba, 2007).

2. Essential monitoring for fluid and electrolyte imbalance and respiratory function (Newfield, Hinz, Tilley, Sridaromont, &Maramba, 2007).

3. Helps in distinguishing normal cyclic periodic breathing pattern from true apneic spells, which are particularly common prior to 30 weeks gestation (

4. Such positioning may facilitate respiration and reduce apneic episodes (

5. Maintains a patent airway for gas exchange (Newfield, Hinz, Tilley, Sridaromont, &Maramba, 2007).

6. Compliance with plan of care (Newfield, Hinz, Tilley, Sridaromont, &Maramba, 2007).

7. Kangaroo holding may be the key intervention that promotes excellent maternal-infant attachment (Johnson, 2005)

8. Despite being stressful and mothers being shocked at the size of some of the very preterm infants, a tour of the unit was beneficial to mothers (Turan, Basbakkal, & Ozbek, 2008).

9. Giving injections to their infant, inserting tubes, intravenous lines and taking blood have been show to be the procedures which cause parental stress (Turan, Basbakkal, & Ozbek, 2008).

Client Response:

1. Patient assessed continuously via monitor, tolerated care well. O2 sats dropped frequently but would rise on own.

2. Patient’s sodium, chloride on high side, Glucose ~70, SaO2 often low, PaCO2 high ~55.

3. Nurse assessed and reassessed entire shift keeping close eye on monitor and addressing any alarms.

4. Nurse had infant positioning on abdomen entire shift when not changing diaper or doing assessment. O2 sat dropped significantly when infant supine.

5. Patient tolerated procedures fair. O2 sats dropped during care.

6. Meds given as ordered, patient tolerated well.

7. Mother held patient for first time 10/17, patient born 10/1, patient tolerated well. Nurses stated O2 sats improved while mother was holding.

8. Nurse stated family was becoming more comfortable visiting and becoming familiar with staff.

9. Nurse stated mother of patient is tolerating procedures well after explanation.

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