Relevant Data:
(subjective/objective data – be
patient specific)
Irregular breathing patterns,
Cyanosis noted form uneven
distribution of gasses
Absence of chest wall movement
Nursing Dx:
Ineffective Breathing Pattern r/t
Impaired regulation aeb Apnea during
active labor. ↓ range.
↓
Intervention:
Assess the frequency and
pattern of breathing;
Observe presence of apnea
and changes in the heart
rate._
Rationale
Infants with apnea have
periods of cessation of ↓-----------------------------------------------------------------------------------------------------------------------------------↓
breathing over 15-20 ↓
seconds accompanied by
↓
bradycardia.
Citation:
J. F. Pagel
The Journal of the American
Board of Family Medicine
July 2007, 20 (4) 392-398;
DOI:
https://doi.org/10.3122/jabf
m.2007.04.060201
Nursing Care Plan Concept Map
Evaluation/Reassessment:
*********PLEASE CITE REFERENCES********
List data r/t outcomes &
Client Initials: D.B. determine if outcome met, not
met, or partially met. Outcome
Medical Diagnosis: met, stimulation provided to stop
←←←←← Apnea
←←←
apnea episodes, baby responded
well.
Goal (opposite of problem)
Outcome met: CPAP provided to
Mother will maintain respiratory status to
relieve stress and energy on the
baseline parameters for pattern rate, depth,
baby. Pulse oximeter remained on
and ease, blood gasses within normal range.
98% to 100%
Desired Outcomes: (opposite of relevant
data)
Pulse oximeter remained within normal
Nursing Interventions
→→→→→→
Intervention:_ Diagnostic/ Therapeutic/ Educational
Assess skin, nail beds,
skin, mucous membranes Intervention: Intervention:_ Intervention:
for pallor or cyanosis. Use of Nasal Administer methylxant Avoid prolonged
Rationale: Continuous positive hines (e.g., suctioning; Discourage
Reveals presence of airway pressure (CPAP). (theophylline, caffeine) taking rectal
hypoxemia Rationale ↓ as prescribed. temperatures and tube
causing cyanosis from an Indicated when ↓
the Rationale: feedings.
Rationale:
uneven distribution of infant remains to have Used as a
gases and blood in the episodes of apnea smooth muscle relaxant Vagal stimulation may
↓ ↓ a ↓ muscle ↓
despite producing and a cardiac cause bradycardia,
lungs, and alveolar
therapeutic level of and central nervous triggering apneic
hypoventilation caused by
↓
airway obstruction and methylxanthine._______ system stimulant. episodes.
Citation:
absence of chest wall ___________________ Citation: J. F. Pagel
movement. ___ J. F. Pagel The Journal of the
The Journal of the American Board
Citation Citation: J. F. Pagel American Board of Family
of Family Medicine July 2007, 20
J. F. Pagel The Journal of the Medicine July 2007, 20
(4) 392-398; DOI:
The Journal of the American American Board of Family https://doi.org/10.3122/jabfm.2007. (4) 392-398; DOI:
Board of Family Medicine Medicine July 2007, 20 04.060201 https://doi.org/10.3122/j
July 2007, 20 (4) 392-398; (4) 392-398; DOI: abfm.2007.04.060201
DOI: https://doi.org/10.3122/j
https://doi.org/10.3122/jabf abfm.2007.04.060201
m.2007.04.060201