NURSING CARE PLAN

Assessment . Nursing Diagnosis Scientific Basis Goals/Objectives Nursing Rationale Evaluation

SUBJECTIVE DATA: N/A

OBJECTIVE DATA: • Newborn Preterm 29 weeks Age of Gestation • Birth weight: 1060 grams • Apgar Score: 4-intubated • Vital Signs: T- 35 °C-35.5 °C HR- 130-150bpm RR- 70-80cpm • Dyspnea noted • Expiratory grunting and nasal flaring noted • Skin pale to cyanotic in color

Laboratory Studies • Chest X-ray - hazy appearance (See table) • BGA - Respiratory Acidosis (See table)

IMPAIRED GAS EXCHANGE related to immaturity of newborn's lungs and lack of surfactant

With deficient surfactant, areas hypo inflation begin to occur & pulmonary resistance increase. The lungs are poorly perfused, affecting gas exchange.

Because surfactant does not form until the 34th week of gestation, as many as 30% of low birth weight infants and as many as 50% of very low birth weights infant are susceptible.

Source: Maternal & Child Health Nursing)

After 1-2 hour of nursing interventions, the neonate will be able to improve ventilation as evidenced by: • infant's skin becomes pinkish in color • respiratory rate of 40-60cpm • infant will be extubated and weaned to nasal CPAP support

INDEPENDENT • Assess respiratory status, noting signs of respiratory distress (tachypnea, dsypnea, grunting, retractions) • Assess skin color for development of cyanosis • Promote rest, minimize stimulation & energy expenditure

COLLABORATIVE • Monitor laboratory/ diagnostic status as appropriatea

• Tachypnea indicatea respiratory distress esp when RR is >75cpm after the first hour of life. Expiratory grunting represents attempt to maintain alveolar expansion, nasal flaring is a compensatory mechanism to increaaw diameter of nares & increase oxygen intake. • Lack of oxygenation will result in cyanosis • To decrease the metabolic rate & oxygen consumption • Laboratory results reveals & prevents any further complications

Goal Partially Met After 1-2 hour of nursing intervention the infant ventilation improved as evidenced by: • Infant skin is pinkish in color • RR of 60-70cpm • infant was extubated and weaned to nasal CPAP

NURSING CARE PLAN

Assessment . Nursing Diagnosis Scientific Basis Goals/Objectives Nursing Rationale Evaluation

SUBJECTIVE DATA: N/A

OBJECTIVE DATE: • Preterm 29 weeks • Tachypnea noted RR 70-80cpm • Episodes of apnea • O2 saturation 85-90%

INEFFECTIVE BREATHING PATTERN related to immature neurologic & delayed pulmonary development

A premature lung is structurally underdeveloped for postnatal life. To add, the premature delivery & the inadequate pulmonary surfactant. A deficiency in surfactant, which functions to decrease the surface tension within the alveoli. Without surfactant the infant experience diffuse atelectasis, decreased pulmonary compliance, ventilation, perfusion, mismatching & significant in the work of breathing.

Source: Gelli's & Kagan's Current Pediatric Therapy by Burg Ingelfinger p.261

After 1-5 hour of nursing intervention , the infant experience effective breathing pattern as evidenced by: • RR will be between normal range 40-60cpm • shows no episodes of apnea

INDEPENDENT • Assess respiratory rate & pattern • Provide tactile stimulation during periods of apnea • Position infant on side

DEPENDENT • Provide respiratory assistance as needed as per Doctor's order (See table)

• Assessment provides information about the neonate's ability to initiate & sustain an effective breathing pattern • Stimulation of the sympathetic nervous system increases respiration • Lying on the side position facilitates breathing • Assistance helps the newborn by clearing the airway & promoting oxygenation

After 1-5 hour of nursing intervention, goal is fully met, the infant experienced an effective breathing pattern as manifested by: • RR is between normal range 55-60cpm • shows no episode of apnea

NURSING CARE PLAN

Assessment . Nursing Diagnosis Scientific Basis Goals/Objectives Nursing Rationale Evaluation

SUBJECTIVE DATA: N/A

OBJECTIVE DATE: • Preterm 29 weeks • Weight: 1060 grams • LOC: Lethargic • Capillary refill time of 3 seconds • Intergumentary Status: - Pale legs, moderate pallor - Cool & dry skin - Turgor less than 3 seconds

INEFFECTIVE THERMOREGULATION related immaturity and lack of subcutaneous & brown fat

The preterm newborn has a great deal of difficulty attaining body temperature because it has a relatively large surface area per kilogram of body weight. In addition, because the infant does not flex the body well but remains in an extended position. Rapid cooling from evaporation is likely to occur. The preterm infant has little subcutaneous fat for insulation & poor muscular development does not allow the child to move actively 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.

Maternal & Child Health Nursing 4th Ed. By Pilliteri p.741

After 1-2 hour of nursing intervention, the infant will maintain normal body temperature as evidence by: • Temperature of 36.5 °C-37.5 °C • Warm & dry skin

INDEPENDENT • Monitor the neonate's body temperature • Place the infant under pre warmed radiant warmer and dry thoroughly & quickly • Avoid placing infant on cold surface or using cold instrument in assessment• Incubator/Isolette temperature should be kept monitored

• To determine the need for intervention & the effectiveness of therapy• Drying quickly & placing on warm, dry surface prevent heat loss from evaporation • Cold surface & instrument increase heat loss by conduction • Helps conserve heat in the body

After 1-2 hour of nursing intervention, goal is fully met, the infant shows a stable body temperature as evidenced by:

• Body temperature of 36.7 °C • Infant has warm & dry skin

NURSING CARE PLAN

Assessment . Nursing Diagnosis Scientific Basis Goals/Objectives Nursing Rationale Evaluation

SUBJECTIVE DATA: N/A

OBJECTIVE DATA: • 1 day old male • Skin jaundice in color • Exposed on double phototherapy • Body Temp: 36.7 °C-37 °C

Laboratory: • High Bilirubin level after 24 hours of age 151.8 umol/L (See table)

RISK FOR INJURY related to Phototherapy light

Phototherapy exposes the newborn to high intensity light. Because it is not known if phototherapy injures the delicate structure of the eye, particularly the retin, it is important to use eye patch over the closed newborn's eyes.

Skin breakdown & fluctuation of temperature is also possible considering that the infant has delayed growth & development & ineffective thermoregulation.

Ladewig et al. Contemporary Maternal-Newborn Nursing Care 6th Ed. p.758

After 4-8 hour nursing intervention the infant will be from injury as evidence by:

• Infant did not have corneal irritation or drainage, skin breakdown or major fluctuation in temperature

INDEPENDENT • Cover the infant's eyes with eye patches while under phototherapy lights • Make certain that eyelids are closed prior to applying eye patches • Inspect eyes each shift for conjunctivitis, drainage & corneal abrasions due to irritation from eye patches • Provide minimal coverage -only on genital area • Avoid use of oily applications on the skin • Reposition infant every 2 hours • Monitor axillary temperature

• Protects retina from damage due to high integrity light • Prevents corneal abrasions • Prevents or facilitates prompt treatment of purulent conjunctivitis • Provides maximal exposure, shielded areas becomes more jaundice, so maximum exposure is essential • Prevents superficial burns on skin • Provides equal exposure of all skin area & prevents pressure area • Hyethermia may result from the increased environmental heat. Additional heat from phototherapy lights frequently cause rise in body temperature. Fluctuations in temperature may occur in response to radiation & convection

After 4-8 hour of nursing intervention, goal is fully met, the infant was free of injury as evidenced by: • Eyes are protected, skin is intact, and maintained a stable temperature

Drug

Drug Name Dosage & Route Action Indication Contradiction Adverse Effects Nursing Responsibility

AMINOPHYLLINE (theophylline ethylenediamide)(am-in-off'i-lin)

Corophyllin , Paladron , Phyllocontin, Somophyllin, Somophyllin-DF, Truphylline

Classifications: BRONCHODILATOR (RESPIRATORY SMOOTH MUSCLE RELAXANT); XANTHINE

Child: IV Loading Dose 6 mg/kg IV over 30 min IV Maintenance Dose 1–9 y, 1 mg/kg/h; >9 y, 0.75 mg/kg/h PO 1–9 y, 1 mg/kg/h times 24 h in 4 divided doses; >9 y, 0.75 mg/kg/h times 24 h in 4 divided dosesInfant: PO/IV 6–11 mo, 0.87 g/kg/h; 2–6 mo, 0.5 mg/kg/hNeonate: PO/IV 0.16 mg/kg/hNeonatal ApneaNeonate: PO/IV Loading Dose 5 mg/kg PO/IV Maintenance Dose 5 mg/kg/d divided q12h

Aminophylline is a salt of theophylline with effects similar to those of other xanthines (e.g., caffeine and theobromine). Action is dependent on theophylline content (approximately 80%) and is measured as theophylline in the serum.

To prevent and relieve symptoms of acute bronchial asthma and treatment of bronchospasm associated with chronic bronchitis and emphysema.

Hypersensitivity to xanthine derivatives or to ethylenediamine component; cardiac arrhythmias. Safety during pregnancy (category C) or lactation is not established.

CNS: Nervousness, restlessness, depression, insomnia, irritability, headache, dizziness, muscle hyperactivity, convulsions. CV: Cardiac arrhythmias, tachycardia (with rapid IV), hyperventilation, chest pain, severe hypotension, cardiac arrest. GI: Nausea, vomiting, anorexia, hematemesis, diarrhea, epigastric pain.

Assessment & Drug Effects

Monitor for S&S of toxicity (generally related to theophylline serum levels over 20 mg/mL). Observe patients receiving parenteral drug closely for signs of hypotension, arrhythmias, and convulsions until serum theophylline stabilizes within the therapeutic range. Note: High incidence of toxicity is associated with rectal suppository use due to erratic rate of absorption. Monitor & record vital signs and I&O. A sudden, sharp, unexplained rise in heart rate may indicate toxicity. Lab tests: Monitor serum theophylline levels. Note: Older adults, acutely ill, and patients with severe respiratory problems, liver dysfunction, or pulmonary edema are at greater risk of toxicity due to reduced drug clearance. Note: Children appear more susceptible to CNS stimulating effects of xanthines (nervousness, restlessness, insomnia, hyperactive reflexes, twitching, convulsions). Dosage reduction may be indicated.