Newborn Ncps

7/29/2019 Newborn Ncps

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CUES/ DATA NURSINGDIAGNOSIS

RATIONALE GOALS/OBJECTIVES

NURSINGINTERVENTIONS

RATIONALE EVALUATION

Subjective:

n/a

Objective:

- Preterm birth(34 wks and2days)

- With Oxygenhoodregulated at

10 liters perminute- RR:58 cycles/

min- Episodes of

apnea (6- 10secs)

- O2 saturationof 91%

Ineffectivebreathing

patternrelated toimmatureneurologicand delayedpulmonarydevelopment

A prematurelung is

structurallyunderdeveloped for postnatallife. To add,the prematuredelivery andthe inadequatepulmonarysurfactant. Adeficiency in

surfactant,which functionsto decreasethe surfacetension withinthe alveoli.Withoutsurfactant, theinfantexperiences

diffuseatelectasis,decreasedpulmonarycompliance,ventilationperfusionmismatching,and significant

After 30 minutesof nursing

interventions, theinfant willexperience aneffectivebreathing patternas manifested by

- Infants RRis between40 and 60

-Infant willexperienceno apnea

INDEPENDENT:(1) assess RR

and pattern

(2) providerespiratoryassistance asneeded (oxygenhood)

(3) position infant

on side with arolled blanketbehind his back

(4) provide tactilestimulation duringperiods of apnea

(1)

assessmentprovidesinformationaboutneonatesability toinitiate andsustain aneffectivebreathing

pattern(2)assistancehelps thenewborn byclearing theairway andpromotingoxygenation(3) lying on

the sidepositionfacilitatebreathing(4)stimulationof thesympatheticnervous

After 30 minutesof nursing

interventions,goal is partiallymet, the infantexperienced aneffectivebreathing patternas manifested by

- InfantsRR was

between40 and 60- Infant

experienced lessepisodesof apnea


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increase in thework ofbreathing.

SOURCE;Gellis andKagansCurrentPediatricTherapy byBurgIngelfinger p.261

systemincreasesrespiration

DelmarsMaternal-InfantNursingCare Plans2nd edition byKarla Luxnerp. 223


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CUES/DATANURSING

DIAGNOSISRATIONALE

GOALS/EXPECTED

OUTCOMES

NURSING

INTERVENTIONRATIONALE EVALUATION

Subjective:

N/A

Objective:

Gestationalage of 34weeks 2/7

Current

weight: 2.0kgs

Neurologicalstatus:

LOC:Lethargic

Capillary refilltime of 3seconds.

IntegumentaryStatus:pale legs,

Moderatepallor

cool and dryskin

Turgor: lessthan 3

Ineffective

thermoregulation

related to

immaturity and

lack of

subcutaneous

and brown fat

The preterm

newborn has

a great deal

of difficulty

attaining body

temperature

because she

has a

relativelylarge surface

area per

kilogram of

body weight.

In addition,

because the

infant does

not flex the

body well butremains in an

extended

position.

Rapid cooling

from

evaporation is

likely to

After 1 hour of

nursing intervention,

patient will maintain

normal body

temperature from

36.5-37.5

1. Staff memberswill take stepsto maintainneonatesbodytemperature atnormal level.Pt. will have aand warm, dryskin

INDEPENDENT:

Monitor theneonatesbodytemperatureuntil discharge

Drynewbornthoroughly andquickly anddiscard the wetblanket. Placethe infant undera pre warmed

Todeterminethe needforinterventionand theeffectiveness oftherapy.

Dryingquickly andplacing andplacing on awarm, drysurfaceprevent heatloss from

After 1 hour of

intervention, thegoal is fully met.

The neonate

maintained a

stable body

temperature at 36

.7C evidenced

by:

1.

staffmemberskeptneonatesbodytemperatureat normallevel.neonate haswarm, dryskin


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seconds

neonate isplaced in theisolation room

Temperature:35.5 C

Mild shivering

Baby isplaced in anextendedposition

Poor muscletone

Labs:

IncreasedHemoglobin(198 g/l)

increasedHematocrit(0.58 g/l)

increasedWBC (10.3 x10 d/l)

occur.

The preterm

infant has

littlesubcutaneous

fat for

insulation and

poor

muscular

development

does not

allow the

child to moveactively as

the older

infant does to

promote heat.

The preterm

infant also

has limited

amount of

brown fat;

special tissue

present in

newborns to

maintain body

temperature.

2. parents willexpress

understandingof neonatesthermoregulatorydisturbanceandthermoregulation

radiant warmer.

Avoid

placing infanton cold surfaceor using coldinstrument inassessment.

Ambienttemperature ofthe room wherethe newborn iskept should bemonitored

Mummifyand use thickblankets tocover thepatient

Teach themother aboutthe infantsneed forwarmth and tokeep theinfants headcovered

evaporation.

Coldsurface and

instrumentincreaseheat loss byconduction

Topreventexcessivecooling.

Helpsconserveheat in thebody

Theinfants headprovides alarge surfacearea for heatloss

2. parentsexpressed

understanding ofneonatesthermoregulatorydisturbanceandthermoregulation


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Source:

Maternal and

Child HealthNursing, 4th

Ed. By

Pillitteri,

p.741

Teach familymembersabout:

-signs and

symptoms of

altered body

temperature,

such as cool

extremities.

- factors inhome that

contribute to

neonatal heat

loss and ways

to minimize

heat loss

-importance of

contacting ahealth care

provider when

problems

related to temp

regulation

Carefulteaching

allowsfamilymembersto take anactive roleinmaintainingtheneonateshealth.

Sources:

Ladewig et al.

Contemporary

Maternal-

Newborn

Nursing care

6th ed. P645

Taylor Et.Al

Nursing

Diagnosis

Reference

Manual 6th Ed.

pp. 525-526


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NURSING GOA S/EXPECTED NURSING


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CUES/DATANURSING

DIAGNOSISRATIONALE

GOALS/EXPECTED

OUTCOMES

NURSING

INTERVENTIONRATIONALE EVALUATION

Subjective:

N/A

Objective:

Absentsuckingreflex

Birth weight:2.3 kgs

CurrentWeight: 2.0kgs

Ideal body

weight: 2.2 4 kgs

Stoolcharacteristics: loose,brown withtinge ofgreen in color

Type offeeding:

discontinuation of OGT,breastfed.

Poor muscletone

paleconjunctivae

Pale mucousmembrane

Imbalanced

nutrition:

less than

body

requirements related to

ineffective

suck reflex

Nutritional

problem arise

with the

preterm infant

because thebody is

attempting to

continue to

maintain the

rapid rate of

intrauterine

growth.

Therefore, the

pretermnewborn

requires a

larger amount

of nutrients in

a diet than the

mature infant

does.

Nutritional

problems are

compounded

by the preterm

infants

immature

reflexes,

which makes

swallowing

and sucking

difficult.

After 1 day of

nursing intervention,

the neonate will

receive adequate

fluid and nutrients

for growth during

hospitalization:

1. establisheffective suckand swallowreflexes,

allowing foradequatenutritionalintake

2. maintaingood skinturgor, moistmucousmembraneand flat , softfontanels

INDEPENDENT:

Assess the

neonates sucking

pattern. Try to

correct ineffectivesucking pattern

Make sure the

neonates tongue is

properly positioned

under the nipple of

the mother

Monitor the neonate

for signs of

dehydration, such

as poor skin turgor,

dry mucous

membranes,

increase orconcentrated urine,

& sunken fontanels

and eyeballs.

To help

eliminate

ongoing

difficulties

To enable the

neonate to suck

adequately

To establish the

need for

immediate

medical

intervention

After 1 day of

nursing

intervention, the

goal is partially

met, as

evidenced by:

1. establishedan effectivesuck andswallowreflexes,allowing foradequatenutritionalintake

2. maintainedgood skinturgor,moistmucousmembraneand flat ,

softfontanels


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Subjective:

-N/a since apotential diagnosis

Objective:- 34 2/7

weeks ofgestation

- Immaturegag reflex

- Absence ofsuckingreflex

- With OGT

- RR: 52breaths perminute

Risk foraspirationrelated toprematureinfants

impairedsuckingreflex

The anatomic

and functional

immaturity of

preterm

infants elevate

their risks for

minor and

more

significant

complications,

like aspiration

in which entry

of secretions,

solids, orfluids into the

trachea

passages is

high. All

newborns

have poor

muscle tone

After 2 hoursof nursinginterventions,the infant willnot

experienceaspiration

- the infant willmaintain clearbreath sounds

INDEPENDENT:(1) elevate headof bed or placechild in semiFowlers position,

or position headof the babyupright

(2) observe forsigns to stopfeedingmomentarily,

such as elevatedeyebrows,wrinkled forehead

(3) burpfrequentlybecause ofexcessive airswallowing

(1) semifowlersrelaxestension of the

abdominalmuscles,allowing forimprovedbreathing

(2)to allowthe infant torest

(3) infants areparticularlysubject toaccumulationof gas in the

After 2 hoursof nursinginterventions,the infant didnot

experiencedaspiration

- the infantmaintainedclear breathsounds


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of the cardiac

sphincter of

the

esophagus,

thus causingregurgitation.

Newborns

cough reflex is

not well

developed.

Moreover,

during the first

few days of

life, the

newborn has

increased

mucus.

Source:

Ladewig et al.

ContemporaryMaternal-

Newborn

Nursing care

6th ed. P 653

(4) hold an infantwith his headelevated duringfeeding andposition her in aninfant seat afterfeeding

(5)instruct thefamily membersin the home careplan

stomachwhile feeding,and this cancause

considerableagitation tothe childunless it isburped

(4)suchpositioninguses gravityto prevent

regurgitationof stomachcontents andpromoteslungexpansion

(5) the childand thefamilymembersmustdemonstratethe ability toensureadequatehome carebeforedischarge


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Source:NursingDiagnosis

ReferenceManual 6th

edition byRalph andTaylor pp.394- 395

CUES/DATA NURSINGDIAGNOSIS

RATIONALE GOALS andOBJECTIVES


RATIONALE EVLUATION

Subjective:

n/a since itis apotentialdiagnosis

Objective:

-10 days old

-temperature:36.2C-jaundicedskin- patient is inphoto therapyfor 4 days- on breast-milk, OGT

Risk for injuryrelated to useofphototherapylight

Phototherapyexposes thenewborn to highintensity light.Because it is notknown ifphototherapyinjures thedelicate structureof the eye,

particularly theretina, it isimportant to useeye patch overthe closednewborns eyes.Skin breakdownand fluctuation oftemperature is

After 8 hoursof nursinginterventionsthe neonatewill be free ofinjuryInfant did nothave cornealirritation ordrainage, skin

breakdown, ormajorfluctuation intemperature.

INDEPENDENT:(1)Cover babyseyes with eyepatches whileunderphototherapylights.(2) Make certainthat eyelids areclosed prior to

applying eyepatches.(3) Remove babyfrom underphototherapy andremove eyepatches duringfeeding.(4) Inspect eyes

(1)Protectsretina fromdamage due tohigh intensitylight.

(2)Preventscornealabrasions.

(3) Providesvisualstimulation andfacilitatesattachmentbehaviors.(4)Prevents or

After 8 hoursof nursinginterventions,the goal isfully met.Neonate wasfree of injury.The infantseyes areprotected,

skin is intact,andmaintained astabletemperature.


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feeding-consumesfivediapers/day

-labs:increasedbilibrubinlevels

also possibleconsidering thatthe infant hasdelayed growth

and developmentand ineffectivethermoregulation.

Source: Ladewiget al.ContemporaryMaternal-Newborn Nursingcare 6th ed.P758

each shift forconjunctivitis,drainage andcorneal abrasions

due to irritationfrom eye patches.(5) Administerthorough perianalcleansing witheach stool.(6) Provideminimal coverage only of diaperarea.

(7) Avoid use ofoily applicationson the skin.(8) Repositionbaby every 2hours.

(9) Observe forbronzing of skin.

facilitatesprompttreatment ofpurulent

conjunctivitis.

(5) Frequentdefecatingincreases risk ofskin breakdown.(6) Providesmaximalexposure,shielded areasbecome morejaundices, somaximumexposure isessential.(7) Preventssuperficial burnson skin.(8) Providesequal exposureof all skin areasand preventspressure areas.(9) Bronzing isrelated to use ofphototherapywith increaseddirect bilirubinlevels or liver


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(10) Place

plexiglas shieldbetween babyand light. Monitorbabys skin andcore temperaturefrequently untiltmperature isstable.

(11) Checkaxillarytemperature.

damage; maylast for 2-4months.(10)Hypothermia

andhyperthermiaare commoncomplications ofphototherapy.Hypothermiaresults fromexposure tolights,subsequentradiation, andconvectionlosses.(11) Hyethermiamay result fromthe increasedenvironmentalheat.Additionalheat fromphototherapylights frequentlycauses rise inbabystemperature.Fluctuations intemperaturemay occurinresponse toradiation and


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convection.





Subjective:

-n/a since apotentialdiagnosis

Objective:

- patient isdiagnosed with

neonatalsepsisuponadmission

- -RR; 58cycles/min

- HR: 148

Risk forinfection r/tspread ofpathogenssecondaryto identifiedsepsis andimmatureimmunesystem

The

newborns

immune

system is not

fully activated

until some

time after

birth.

Limitation in

the newbornsinflammatory

response

result in

failure to

recognize,

localize, and

destroy

After 8 hours ofnursinginterventions theinfant will notexperiencespread ofinfection asmanifested by

- InfantsHRremains


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bpm- Labs:IncreasedWBC levels

invasive

bacteria thus,

increasing

risk for

infection.

Source:

Ladewig et al.

Contemporary Maternal-

Newborn

Nursing care

6th ed. P. 580

(3) place infant inisolette/ isolationroom per hospitalpolicy

(4) maintainneutral thermalenvironment

(5) assess TPR &BP, auscultatebreath sounds

(6) providerespiratorysupport (oxyhood)

(3) placing theinfant in an isoletteallows closeobservation of the

ill neonate &protects otherinfants frominfection(4) a neutralthermalenvironmentdecreases themetabolic needsof the infant. Theill neonate hasdifficultymaintaining astable temp.(5) assessmentsprovideinformation aboutthe spread ofinfection,increased RR andHR, decreased BPare signs ofsepsis. Spread ofinfection maycause resp.distress(6) resp. supportmay be neededduring the acute


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(7) feed infant asordered (OGT)

(8) monitor labresults asobtained. Notifycare giver ofabnormal findings

(9) monitor infantfor hypoglycemia,jaundice,development ofthrush, or signs ofbleeding

phase of theinfection toprevent additionalphysiological

stress(7)nutritionalneeds mayincrease duringinfection while theinfant may feedpoorly. OGfeedings ensurethat nutrient needsare met if theinfant is too ill tosuck effectively(8) lab resultsprovideinformation aboutthe pathogen andinfants responseto illness andtreatment(9) assessmentscoagulationprovide informationabout thedevelopment ofcomplications ofinfection:hypoglycemia,hyperbilirubenia,opportunistic


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DEPENDENT:

(10) administer IVfluids as ordered

(D10IMB)(11) administerantibiotics asordered

infections, andcoagulationdeficits(10) IV fluidsnhelp

maintain fluidbalance(11) antibiotics actto inhibit thegrowth of bacteriaand destruction ofbacteria.DelmarsMaternal- InfantNursing CarePlans 2nd editionby Karla Luxner p.237


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Cues Nursing

Diagnosis

Rationale Goals and

Objectives

Interventions Rationale Evaluation


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Objective:

Patient is

onphototherapy for 4days

Consumes5 diapersper day

Slightlyjaundice incolor

Dry skin

Patient insupineposition

Has noclothes onduringphototherapy, onlymittens,socks, anddiapers

Has eyecoverduringphototherapy

Risk for

Impaired skin

integrity relatedto exposure to

high intensity

light

secondary to

phototherapy

The newborn

lies in one

position for along period of

time that may

result in skin

breakdown.

Due to lack of

adipose

tissue, the

pressure

exerted bybony

prominences

on the skin is

greater thus

increases the

risk of skin

breakdown.

Source:

Ladewig et al.

Contemporary

Maternal-

Newborn

Nursing care

After 8 hours of

nursing

intervention

1. Patients skin

will remain

intact

No signs ofskinbreakdown

INDEPENDENT:

Changeposition every2 hours

Monitorskin for rashes

Patientposition changeswill allow exposureof the phototherapylights to all areas ofthe body that areuncovered.Pressure areasmay develop ifnewborn lies in oneposition for anextended period oftime.

Patient maydevelop amaculopapular rash

After 8

hours of

nursing

intervention,

goal is fullymet.

Patients

skin

remained

intact as

evidenced

by:

No signsof skinbreakdown


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6th ed. P763 and bronzingevery 8 hours.

Inspectperianal areaafter eachdiaper changefor signs ofbreakdown

Avoidusing lotions orointments onthe newbornsskin

which is transientside effect ofphototherapy

Newbornsunder phototherapylights haveincreased loosegreen acidic stoolswhich can beirritating to the skin.The diaper areashould bethoroughly cleanedafter each soileddiaper to preventskin breakdown.

Lotions andointments maycause skin to burnif applied toexposed areas

duringphototherapy.

Source: Ladewig et al.

Contemporary Maternal-

Newborn Nursing care

6th ed. P759- 761


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Newborn Ncps

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