Nursing Care Plan


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Medical Diagnoses: Ineffective breathing pattern r/t inadequte pulmonary development, Impaired gas exchange and Ineffective thermoregulation


1. Nursing dx:  Ineffective breathing pattern r/t inadequte pulmonary development secondary to prematurity aeb birth at 24 weeks gestation, xray suggestive of left lower lobe atelectasis and sufactant deficiency disorder, patient on endotracheal ventilation.  
Data:  Patent ductus arteriosis (PDA) causes breathing problems 
 
medial dx: respiratory distress syndrome 
 
r/t # 2, 3

2. Nursing dx:  Impaired gas exchange r/t inadequate surfactant secondary to pulmonary immaturity aeb PaCO2 81.6, pH 7.06, and  xray suggestive of surfactant deficiency disorder. 
 
Data: PaCO2 81.6, pH 7.06 indicative of respiratory acidosis
 
PDA and PFO   r/t # 1, 3 

3. Nursing dx: Ineffective thermoregulation r/t lack of subcutaneous fat secondary to prematurity aeb low birth weight and lack of subcutaneous fat stores, gestational age 24 weeks, current weight 0.566kg.
 
Data: poor muscle tone, baby in isolette
 
fluctuation in body temp above and  below normal range   r/t # 1,2,4,5,6,7

4. Imbalanced nutrition, less than body requirements r/t absent sucking reflex secondary to preterm birth aeb type of feeding.  Data: patient on TPN
 
pale mucous membranes
inability to ingest food
  
poor muscle tone, body weight 20 percent or more below ideal
  
r/t # 3,5,6,7 

Demographics: 24 week gestational age, breech female delivered via C/S on 10/17, 1 day old
 
Admitting dx: Respiratory distress syndrome
 
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. Nursing dx:  Impaired skin integrity r/t mechanical factors including pressure secondary to foot through cerlage aeb bruising and discoloration on right leg and discoloration on extremities. 
 
Data: patient foot was through cerlage, bruised badley
 
xray shows no broken bones    skin very thin and fragile
     
patient has many IVs and lines ran   r/t # 3,4,6
 

6.

Risk for infection r/t immature body systems secondary to prematurity aeb baby born at 24 weeks, baby in contact isolation. Data: baby immune system not developed due to preterm birth
  
Child has many visitors including school aged children r/t # 3,4,5

7. Risk for delayed growth and development r/t prematurity aeb birth at gestational age 24 weeks. 

Data:  pt premature
  
TPN   inability to ingest    r/t # 4, 8

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: mother currently admitted to hospital baby in isolette, contact isolation baby only a day old so not being held  r/t #7


NANDA Diagnostic Statement: Ineffective breathing pattern r/t inadequte pulmonary development secondary to prematurity aeb birth at 24 weeks gestation, xray suggestive of left lower lobe atelectasis and surfactant deficiency disorder, patient on endotracheal ventilation.

Behavioral Outcome / Goal: Patient will demonstrate improvements toward effective breathing pattern daily as evidenced by normal breath sounds, arterial blood gases within normal limits, and no evidence of cyanosis until discharge date.  Patient’s respiratory function will not decline for duration of stay in NICU.  


Nursing Interventions:

1.Assess respiratory rate and pattern

 

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

 

3. Monitor body temperature and maintain optimal body temperature.

 

4. Position patient to facilitate optimum breathing patterns.

 

5. Maintain airway clearance.

 

6. Administer medications as indicated.

 

7. Encourage visiting, teaching parents how to care for their child and involving them in decision making. (Mok & Leung 2006).

 

8. Educate the mother regarding the  NICU environment. Provide a tour of the NICU.

 

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

Rationale:

1. Assessment provides information about neonate’s ability to initiate and sustain an effective breathing pattern (Newfield, Hinz, Tilley, Sridaromont, &Maramba, 2007).

2. Essential monitoring for body systems balance (Newfield, Hinz, Tilley, Sridaromont, &Maramba, 2007).

3. Permits early recognition of ineffective thermoregulation (Newfield, Hinz, Tilley, Sridaromont, &Maramba, 2007).

4. Allows gravity to assist in lowering the diaphragm, and provides greater chest expansion (Newfield, Hinz, Tilley, Sridaromont, &Maramba, 2007).

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

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

7. Nurses can boost parental self-esteem and confidence in the

NICU by encouraging these important aspects (Turan, Basbakkal, & Ozbek, 2008).

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 theirinfant, inserting tubes, intravenous lines and taking bloodhave been shown to be the procedures which cause parental stress  (Turan, Basbakkal, & Ozbek, 2008).

Client Response:

1.Patient tolerated procedures well for most part, RR rate on assessment 55, significant chest movement.

2. Patients glucose 91, electrolytes somewhat within range, highs and lows were not of significant concern.  ABGs of concern, PaCO2 81.6, xray ordered.

3. Termperature 98.7.

4. Patient laying supine entire shift, moving extremities often.

 

5. Patient on endotracheal ventilation with patent airway.

 

6. Meds given as ordered, patient tolerated well. Dopamine order increased throughout shift.

7. Patient had many visitors on 10/18 including mother, father, grandmother, sister, friends of the family. Nurses explained as patient advances, there will be opportunity for them to be involved.

8. Nurse explained room arrangement and encouraged mother to visit.  Mother was shown around the unit.

 

9. The nurse explained several procedures including medications, ventilation, and feedings to the mother and grandmother during their visit.

Summarize impressions of client progress toward outcomes / problem resolution:The goal of  Patient will demonstrate improvements toward effective breathing pattern daily as evidenced by normal breath sounds, arterial blood gases within normal limits, and no evidence of cyanosis until discharge date and Patient’s respiratory function will not decline for duration of stay in NICU has not been met.  More time is needed to truly evaluate the interventions and goals.  The patient’s airway has remained clear, however more time is needed for the lungs to develop.  This care plan is effective in monitoring and management of the patient’s diagnosis of Ineffecitve breathing pattern, however more time is needed to see if this care plan is effective in resolving the diagnosis.  Because the patient is only 1 day old, time to advance and develop will determine what changes need to be made to facilitate her breathing pattern

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