ncp proper 1

8/3/2019 Ncp Proper 1

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NURSING CARE PLAN PROPER 1

Problem 1:

Nursing Diagnosis: Impaired Gas Exchange related to immaturity of the lungs secondary to premature t/c hyaline membrane disease

Goal: After all nursing interventions, the patient will be able to breathe normally without any devices such as oxygen therapy, incubator and being stimulated, and injecting surfactants

Objective: After a week of nursing interventions, the patient will be able to manifest signs and symptoms of improvement of normal breathing continuously by

a. Reduce suffering of RDS, with reduces work of breathing

b. Maintain periodic breathing pattern and normal vital signs

c. Maintain PaO2 and PaCO2 levels within normal

d. Leading to normal laboratory or diagnostic studies

CUES EXPLANATION

Subjective:

Objectives:

On incubator

On oxygen therapy @ 1 lpm

With D5 IMD x 7-8mgtts

Afebrile

Apgar score of 6-7 @1.5 min

With a current weight of 1.2 kg

Current VS: RR-32; CR-128; T-36.8C

Temperature fluctuates easily With slight clammy pale extremities

Abnormal breathing pattern with episodes of

apnea

Lies in an extended position

Low muscle tone and activity

Thin and less body fat

A premature baby, or preemie, is born before the 37th

week of pregnancy. Premature birth occurs in between 8

percent to 10 percent of all pregnancies in the United

States. Because they are born too early, preemies weigh

much less than full-term babies. They may have health

problems because their organs did not have enough time

to develop. Preemies need special medical care in a

neonatal intensive care unit, or NICU. They stay there

until their organ systems can work on their own.

Respiratory distress syndrome (RDS) is a breathing

disorder that affects newborns. RDS is more common in

premature infants because their lungs aren't able to make

enough surfactant. Surfactant is a liquid that coats the

inside of the lungs. It helps keep them open so that

infants can breathe in air once they're born.

Without surfactant, the lungs collapse and the infant has

to work hard to breathe. He or she might not be able to

breathe in enough oxygen to support the body's organs.



INTERVENTIONS RATIONALE CRITERIA FOR EVALUATION EVALUATION

Dx:

Assess respiratory status, noting signs

of respiratory distress such as

tachypnea , bradypnea or periods of

apnea, grunting, retractions or use of

accessory muscles such as abdominal

muscle or nasal flaring

Monitor body temperature of not

<36.6 C and >38 C together with the

cardiac rate of

Monitor fluid intake and output;

Weight infant as indicated by protocol

Monitor for signs of necrotizing

enterocolitis

Monitor oxygen therapy closely and

record hourly; adjust level and/or

limit duration of administration as

needed

Observe for evidence and location of

Tachynea, bradypnea or apnea

indicate respiratory distress,

especially when respirations are

>75cpm or <30cpm. Expiratory

grunting represents an attempt to

maintain alveolar expansion; use of

accessory muscles is a compensatory

mechanism to increase diameter of

nares and increase oxygen intake.

Cold stress increases infant’s oxygen

consumption, may promote acidosis,

and further impair surfactant

production and a slight increase or

decrease in environmental

temperature san lead to apnea

Dehydration impairs ability to clear

airways because mucus becomes

thickened. Overhydration may

contribute to alveolar ifiltration or

pulmonary edema. Weight loss and

increase urine output may indicatediuretic phase of RDS/HMD.

Hypoxia may cause shunting of blood

to brain, thereby reducing circulation

to the intestines, with resultant

intestinal cell damage and invasion by

gas-forming bacteria

Amount of oxygen administered is

determined individually, based on

capillary blood samples. Prolonged

high levels of serum oxygen

combined with prolonged high

pressure may predispose infant to bronchopulmonary dysplasia and

retinal damage.

Cyanosis is a late sign of low Po2 and

does not appear until there is slightly

more than 3g/dl of reduced Hgt in

Goal:

Goal is fully met if patient

breathe normally without any

devices such as oxygen therapy,

incubator and being stimulated,

and injecting surfactants

Goal is partially met if patientnormally breath with one or two

of any devices such as oxygen

therapy, incubator and being

stimulated, and injecting

surfactants

Goal is no met if patient breath

with the help more or more

devices such as oxygen therapy,

incubator and being stimulated,

and injecting surfactants

Objectives:

Objectives are fully met if patientmanifest all signs and symptoms of

improvement of normal breathing

continuously by

a. Reduce suffering of RDS, with

reduces work of breathing

b. Maintain periodic breathing

pattern and normal vital signs

c. Maintain PaO2 and PaCO2 levels

within normal

d. Leading to normal laboratory or

diagnostic studies

Objectives are partially met if patient

manifest all but not one or two signsand symptoms of improvement of

normal breathing continuously by



b. Maintain periodic breathing

pattern and normal vital signs



cyanosis

Evaluate laboratory or diagnostic

studies such as ABGs, Hgt/Hct, serum

glucose level

Review information related to infant’s

condition, such as length of labor,

type of deliver, apgar score, need for

resuscitation measures at delivery,

and maternal medications taken

during pregnancy or delivery

Investigate sudden deterioration in

condition associated with cyanosis,

diminished or absent sounds, shift of

point maximal impact, bulging of

chest wall or cardiac dysrhythmias

central arterial blood, or 4-6g/dl in

capillary blood or until oxygen

saturation is only 75%-85%, with Po2

levels of 32-41 mmHg.

Hypoxemia, hypercapnia and acidosis

reduce surfactant production. Pa02

levels should be 50-70 mmHg or

higher, PaC02 levels should be 35-

45mmHg and Oxygen saturation

should be 95-100%. Decreased ironstores at birth, repeated blood

sampling and hemorrhagic episodes

increase the likelihood that preterm

infant will be anemic, thereby

reducing the oxygen-carrying

capacity of the blood. Hypoglycemia

or hyperglycemia suggests infection

Prolonged labor increases risk of

hypoxia, and respiratory depression

may follow maternal drug

administration or usage. In addition,

infants who required resuscitative

measures at birth, or those with apgar

scores, may require more intense

interventions to stabilize blood gases

and may have suffered CNS injury

with the damage to the hypothalamus,

which controls respiratory

functioning. Administration of

corticosteroids to mother within 1wk

of delivery fosters the infant’s lung

maturity and surfactant production

Sudden or unexplained deterioration

of respiratory function may indicate

onset of pneumothorax

To do prompt interventions necessary


within normal


diagnostic studies

Objectives are not met if patient did

not manifest all signs and symptoms

of improvement of normal breathing

continuously by



b. Maintain periodic breathing pattern and normal vital signs


within normal


diagnostic studies



Report to physicians all conditions

that needs physician’s presence

Tx:

Administrations of surfactant

(artificial or exogenous)

Place or apply pulse oximeter in

appropriate place such as in lower

extremities and record and change

probe levels hourly

Position infant in supine position with

rolled small towel beneath shoulders

to produce slight hyperextention

Provide prompt tactile stimulations

such as rubbing infant’s back or

tapping or flicking infant’s foot if

apnea occurs

Provide mouth care using saline or

glycerin swabs

Promote rest by minimizing

stimulation if necessary and energy

expenditure

It decreases severity of condition and

associated complications.

Provides constant noninvasive

monitoring oxygen level

Such positioning may facilitate

respiration and reduce episodes of

apnea especially in the presence of

hypoxia, metabolic acidosis or

hypercapnia

Stimulates CNS to promote body

movement and spontaneous return of

respirations.

Helps prevent drying and cracking of

lips associated with absence of oralintake or the drying effects of oxygen

therapy

Reduces metabolic rate and oxygen

consumption.

Edx:

Inform parents about infant’s

behavioral cues and responses to

stressors

Encouraged parental contact

Encourage parents to do hand hygiene

before and after and minimize

handling infant

Encourage parents to provide stroking

So that they can effectively intervene

to minimize stress and facilitate the

infant’s positive adaptation to

entrauterine life

Sometimes, infants experience fewer

or no episodes of apnea or

bradycardia if parents touch and talk to them.

Avoids further abdominal trauma and

infection to the infant

Enhances emotional and stroking



of head, hands and feet and talk to

infant

needs through quiet conversation



PATHOPHYSIOLOGY

Experienced pretermlabor

Results to preterminfant

Immature development of lungs

Lack of pulmonarysurfactant in the

airspaces

Dysfunction of surfactant

Appear as aneosinophilic, amorphoAsmaterial, lining or filling

the air spaces andblocking gas exchange

Causes:

UTI during pregnancy

Lungs will likelycollapse

Increase RRUse of accessorymuscles such as

abdominal muscleand nasal flaring

Impaired gasexchange

Poor pulmonarycompliance

Breathingdeficiency

High surface tensionwithin fluid-lined

airspacesLow lung volume

in expiration

Blood passing through thelungs is unable to pick upoxygen and unload carbon

dioxideBlood oxygen levels fall

and carbon dioxide

rises, resulting in risingblood acid levels and

hypoxiaBlood oxygen levels

fall and carbondioxide rises

Impaired gas

exchange

Hyaline Distress

syndrome

Immature

CNSdevelopment

Ineffective Thermoregulati

on

Smallstomachcapacity

Imbalancednutrition: less

than bodyrequirements

Immatureimmunesystem

Easilytraumatized

tissue

Risk forInfection

Fragile skin

Ineffective

protection

DEATH

Sudden or unexplained deterioration in conditionassociated with cyanosis, diminished or absent

sounds, shift of point maximal impact, bulging of chest wall or cardiac dysrhythmias

Temperaturefluctuates

easily

Lowweight

http://en.wikipedia.org/wiki/Hypoxia_(medical)

http://en.wikipedia.org/wiki/Hypoxia_(medical)

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