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 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 EXPLANATION 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 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

RATIONALE 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.

CRITERIA FOR EVALUATION Goal:

EVALUATION

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 patient normally breath with one or two of any devices such as oxygen therapy, incubator and being stimulated, and injecting surfactants

Monitor body temperature of not

<36.6 C and >38 C together with the cardiac rate of

Cold stress increases infants oxygen

consumption, may promote acidosis, and further impair surfactant production and a slight increase or decrease in environmental temperature san lead to apnea

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 patient manifest 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

Dehydration impairs ability to clear Monitor fluid intake and output;

Weight infant as indicated by protocol airways because mucus becomes thickened. Overhydration may contribute to alveolar ifiltration or pulmonary edema. Weight loss and increase urine output may indicate diuretic phase of RDS/HMD. Monitor for signs of necrotizing enterocolitis 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

Monitor oxygen therapy closely and record hourly; adjust level and/or limit duration of administration as needed 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.

Objectives are partially met if patient

manifest all but not one or two 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

Cyanosis is a late sign of low Po2 and

Observe for evidence and location of does not appear until there is slightly more than 3g/dl of reduced Hgt in

cyanosis

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 Evaluate laboratory or diagnostic

studies such as ABGs, Hgt/Hct, serum glucose level reduce surfactant production. Pa02 levels should be 50-70 mmHg or higher, PaC02 levels should be 3545mmHg and Oxygen saturation should be 95-100%. Decreased iron stores 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

Maintain PaO2 and PaCO2 levels within normal d. Leading to normal laboratory or diagnostic studies Objectives are not met if patient did not manifest 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

c.

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 infants lung maturity and surfactant production Sudden or unexplained deterioration of respiratory function may indicate onset of pneumothorax

Review information related to infants 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

To do prompt interventions necessary

 Tx:

Report to physicians all conditions that needs physicians presence 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 infants back or tapping or flicking infants foot if apnea occurs Provide mouth care using saline or glycerin swabs 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 oral intake or the drying effects of oxygen therapy Reduces metabolic rate and oxygen consumption.

Edx:

Promote rest by minimizing stimulation if necessary and energy expenditure Inform parents about infants behavioral cues and responses to stressors Encouraged parental contact

So that they can effectively intervene

to minimize stress and facilitate the infants 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

Encourage parents to do hand hygiene before and after and minimize handling infant Encourage parents to provide stroking

Enhances emotional and stroking

of head, hands and feet and talk to infant

needs through quiet conversation

PATHOPHYSIOLOGY

Causes: UTI during pregnancy

Temperature fluctuates easily

Ineffective Thermoregulati on Imbalanced nutrition: less than body requirements Low weight Immature CNS development Small stomach capacity

Experienced preterm labor

Risk for Infection Easily traumatized tissue

Ineffectiv e protection

Results to preterm infant Immature development of lungs Lack of pulmonary surfactant in the airspaces

Immature immune system

Fragile skin Appear as an eosinophilic, amorphoAs material, lining or filling the air spaces and blocking gas exchange Blood passing through the lungs is unable to pick up oxygen and unload carbon dioxide Blood oxygen levels fall and carbon dioxide rises, resulting in rising blood acid levels and hypoxia Use of accessory muscles such as abdominal muscle and nasal flaring Breathing deficiency Impaired gas exchange

Low lung volume in expiration Blood oxygen levels fall and carbon dioxide rises Impaired gas exchange

High surface tension within fluid-lined airspaces

Dysfunction of surfactant

Lungs will likely collapse Increase RR Poor pulmonary compliance

Hyaline Distress syndrome

DEATH

Sudden or unexplained deterioration in condition associated with cyanosis, diminished or absent sounds, shift of point maximal impact, bulging of chest wall or cardiac dysrhythmias