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 (nursereview.org)
4. Position infant on abdomen or in supine position with rolled diaper beneath
shoulders to produce slight hyperextension (nursereview.org)
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).
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Rationale:
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 (nursereview.org)
4. Such positioning may facilitate respiration and
reduce apneic episodes (nursereview.org)
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).
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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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