Name___Lora Aquino__________________ Date____02/03/2020_______ Week ______3______

NCP # 1 2 3 (must choose one care plan from each area – L&D, Antep, PP, Nsy, NICU)

WEEKLY PLAN OF CARE – Nursing 314

1. The area I worked today:_NICU_________________________________________

2. Name of the RN I worked with today: _____Rocio_________________________________

3. Select ONE client from your list today. List 2 nursing diagnosis (actual or potential problems),
prioritize them, give the etiology and make a plan of care for this specific client. Problems may be
Physical, Social support, Emotional concerns, Psychological issues, Developmental stage, and Spiritual
needs. Include evidence-based resources such as – Elsevier, LLUCH policies and protocols, and
ACOG/AWHONN standards as related to your clients’ problems and interventions.

Prioritized Problem Etiology (cause) of the Problem
using accepted Nursing
Diagnosis format
1. Ineffective The preterm newborn has a great
thermoregulation deal of difficulty attaining body
related to temperature because she has a
immature relatively large surface area per
temperature kilogram of body weight. In
control and addition, because the infant does
decreased not flex the body well but remains
subcutaneous in an extended position. Rapid
body fat as cooling from evaporation is likely
evidenced by to occur.
need of constant The preterm infant has little
thermal subcutaneous fat for insulation
regulation via and poor muscular development
incubator 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.
SOURCE:
Maternal and Child Health
Nursing, 4th Ed. By Pillitteri,
p.741
Plan of Care (Interventions) you should do
to bring your client to wellness.
1. Monitor axillary temperature at least
every 8 hours; more frequently for
infants at high risk. Regular temperature
monitoring will identify adequate or
inadequate thermoregulation (Glass,
1999, p.188). Axillary temperature is
good indicator of newborn’s surface
temperature (Glass, 1999, p. 188).
2. Provide heat/warm the newborn
using incubators, radiant warmer,
swaddling, and skin-to-skin contact. To
warm the newborn and adequately
maintain accepted thermal range (Wong,
2003, p. 371).
3. Maintain thermal neutral
environment and avoid situations that
might predispose the infant to heat loss,
such as cool air, drafts, bathing, and cold
bedding. To maintain stable body
temperature of the newborn and
decrease the possibility of heat loss
through conduction, convection,
radiation, & evaporation (Wong, 2003,
p. 371).
 2. Ineffective A premature lung is structurally INDEPENDENT:
breathing pattern underdeveloped for postnatal life. 1. Assess RR and pattern. Assessment
related to To add, the premature delivery provides information about
immature and the inadequate pulmonary neonate’s ability to initiate and
neurologic and surfactant. A deficiency in sustain an effective breathing
delayed surfactant, which functions to pattern
pulmonary decrease the surface tension
development as within the alveoli. Without 2. Provide respiratory assistance as
evidenced by surfactant, the infant experiences needed (oxygen hood). Assistance
nasal flaring, diffuse atelectasis, decreased helps the newborn by clearing the
periods of pulmonary compliance, airway and promoting oxygenation
prolonged 22 ventilation perfusion
second apnea and mismatching, and significant 3. Provide tactile stimulation during
fluctuating 02 sat increase in the work of breathing. periods of apnea. Stimulation of the
ranging from 60- sympathetic nervous system
90% SOURCE; increases respiration
Gelli’s and Kagan’s Current
Pediatric Therapy by Burg SOURCE:
Ingelfinger p. 261 Delmar’s Maternal- Infant Nursing Care
Plans 2nd edition by Karla Luxner p. 223

4. What nursing interventions were you able to do for this client today? Did it work? Why or Why not?
Problem 1 &2 (Did your interventions work? Why/why not?)
Baby K was delivered via Emergency Cesarean Section in a Los Angeles hospital at 28 weeks. She was
transported to LLUCH once stabilized per mother’s request since she did all her prenatals in Loma
Linda. She was tested positive for MRSA and was taken to NICU isolation room. While being treated,
she contracted ventilator associated pneumonia and is currently on antibiotic therapy via PICC line. The
baby has an order for physiotherapy to prevent atelectasis, I was able to perform the physiotherapy with
my proctor’s guidance and suction her nose during care, her fluctuating 02 sat from 60-90% stabilized
at 80-90’s. During care, the baby’s temperature was 36.8 so with my preceptor’s assistance, I removed
her blanket and it stabilized at 36.5. And when the mother visited, she wanted to do kangaroo care, even
with all the lines and the baby having non critical desaturation, so we assisted the baby on the mother’s
chest knowing it will benefit both of them and I assisted the mother on putting a blanket on top of the
baby and would occasionally check her temperature via axilary route to make sure the baby’s not having
hypothermia.

5. What cultural, developmental, or spiritual assessments did you assess that would affect your client’s
plan of care?

The only challenge I encountered was that I can’t really ask and talk to my patient which is a preemie on
how she is feeling, if she’s in pain, if she’s gassy or does she need a diaper change. I have to rely on the
subtle cues, like constant desats or if she’s moving a lot, because she’s not developed enough to cry. I
 also have to make sure not to disturb her a lot because if she gets moved a lot, her oxygen saturation
drops to the 60’s, so I have to figure out what exactly she needs and I have to cluster my care. My
preceptor which is her “primary”, she’s very familiar with her and she knows what intervention needs to
be done, she oriented me with what I the baby shows but I think I don’t have the trained eye that she has
with years of practice.

5. What preventive and health promoting education were you able to give your client today? (For
NICU/Nursery clinicals please state the education you taught the parents or care givers if they were
there)

The mother was concerned during kangaroo care that her baby was having periods of apnea which lasted
almost 10 seconds. I reassured the mother that newborns have the tendency to have sleep apnea which
may last <20 seconds. If it lasts more than that then they have to stimulate the infant right away and call
the nurse. Mother verbalized understanding afterwards.

7. One of the objectives of this clinical is to be able to utilize EBP resources to widen your knowledge about
your client’s condition and care. List 2 resources used to assist you in planning the care of your client? (Can
use protocols, clinical practice guidelines, Elsevier. etc)

A. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3287094/

B. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4235060/

8. What was the highlight of your day?

Highlight of my day was seeing the mother sacrifice most of her day in NICU to visit and hold her baby.
The baby was constantly desatting but when the mother did kangaroo care, the baby’s O2 sat stayed at the 90’s
and was so relaxed that she just started passing gas while she was on her mother’s chest. Another one was
listening about the stories my preceptor told and miracles that happened in NICU.

9. What concerns or questions do you have for your clinical instructor?

None at the moment.

Revised 1/2019