ALL INDIA INSTITUTE OF MEDICAL SCIENCES,

RISHIKESH

NURSING CARE PLAN

Neonatal Intensive Care Unit

Submitted to Submitted by
Ms. Shweta Garadi Ms. Archana
Nursing Tutor M.Sc. (N) 1st year
AIIMS, Rishikesh AIIMS, Rishikesh

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INTRODUCTION:
I Archana student of M.Sc. Nursing 1st year was posted in NICU from Jan 18, 2021 to Feb 27,2021. I took care
of neonate, B/o Meenakshi, with complaints of Low birth weight, prematurity, respiratory distress and feed
intolerance. It was an interesting case and there were a lot of opportunities to learn from this case so I decided to
take it for my Nursing Care Plan and cared for the baby.

SOCIO-DEMOGRAPHIC PROFILE:
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Name of the patient: B/o Meenakshi
Age/Sex: 14 days/ Female
Birth weight: 1032gm
UHID No.: 20210001452
Developmental Stage: Neonate
Ward: NICU
Informant: Mother
Address: Dehradun, Uttarakhand
Education: NA
Religion: Hindu
Date of Admission: 07/01/2021
Diagnosis: Very Preterm (29+2 weeks)/ Very Low Birth Weight (1038 gm)/ Respiratory Distress at birth
Name of Consultant: Dr. Sriparna Basu

CHIEF COMPLAINTS:
On admission
Prematurity X since birth
Very low birth weight X since birth
Respiratory Distress X since birth
At Present
Respiratory Distress X since birth
Feed Intolerance X 2nd day of life

HISTORY OF PRESENT ILLNESS:

B/o Meenakshi, born to 27 years old G1P1L1 mother at 29+2 weeks of gestation by normal vaginal delivery on 7
Jan 2021 at 05:20am in view of mother’s premature rupture of membranes and oligohydramnios. Baby had a
weight of 1038 gms and cried immediately at the time of birth with APGAR score of 8 and 9 at 1 and 5 mins
respectively. Subsequently baby developed Intercoastal retractions, Subcoastal retractions, nasal flaring,
grunting sounds and respiratory rate of 78 breaths/min indicative of Respiratory Distress with Downe’s Score of
8 (Severe Respiratory Distress).
On admission to NICU, baby was put on CPAP with Fio 2 21% and PEEP of 7.5cm of H2O. IVF D10 was started
@ 35ml/hr. Antibiotics like Inj. Piptaz, Inj. Amikacin and Inj. Caffeine were started and RBS and BP
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monitoring was done 6th hourly. Baby also developed feeding intolerance from 2 nd day of life when OG feeds
with 4ml of EBM was started every 2nd hourly. Baby was weaned off from CPAP to room air but due to
episodes of desaturation was again put on CPAP with PEEP of 5cm of H 2O and Fio2 of 21%. Gradually OG
feeds with EBM are increased to 15ml/2 hourly and baby is tolerating the feeds but the parents was not satisfied
and took LAMA on 29 Jan 2021.

Past Medical and Surgical History

Not significant

Antenatal History of Mother

Mother is a primigravida, aged 27 years, having Hypothyroidism and on Tab. Thyroxine 25µg/day from 2
years. Also she had oligohydramnios. No other significant findings.

Family History
Baby lives in a nuclear family. Total members in the family are 4. There is no any genetic or hereditary disease
in the family.
S.No Name of member Relationshi Age Education Occupatio Health
. p n Status
1. Mr. Kamal Father 31 years 12th pass Electrician Healthy
2. Mrs. Meenakshi Mother 27 years 10th pass Housewife Healthy

Socio- economic History

Baby lives in own house and belongs to lower middle-class family. Father is the only earning member in the
family.

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Environmental History
Family lives in an urban area. There is proper water and electricity facilities. Drainage facilities are also present.
There are no pet animals.

Personal History
Bowel habits: Passed stools within 24 hours of birth.
Bladder habits: Passed urine within 24 hours of birth.

PHYSICAL EXAMINATION
1. General Appearance
Level of Conscious: Conscious
Grooming: Well groomed
Nourishment: Malnourished
Body built: Thin
Posture: Flexed
2. Vital Signs
Vital Sign Patient value Normal value Remarks
Temperature 36.8°C 36.5-37.5°C Normal
Pulse 172° b/min 110-160 b/min Tachycardia
Respiration 56 breaths/min 30-60 breaths/min Normal

3. Anthropometric Measurements
Parameter Patient Value Normal Value Inference
Length 39 cm 45-50cm Decreased
Weight 1032gm 2500-3500gm Decreased
Chest Circumference 23cm 31-33 cm Decreased
Head Circumference 25cm 33-35cm Decreased

4. Head to toe examination

 Skin
Color: Plethoric
Temp: Warm to touch
Texture: Moist skin

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 Turgor: Good elasticity
No rashes, ecchymosis, or edema
 Head
Scalp: Normal. No caput succedaneum, no pruritis
Shape: Symmetric
Hair distribution: Equal
Hair texture: Soft hair
Hair colour: Black
Posterior Fontanel: Palpable
Anterior Fontanel: Palpable
Sutures: Normal
 Face
Symmetric, no puffiness, no cyanosis, no facial edema
 Eyes
Eyelids: Normal, no ptosis
Eye ball: Normal, no exopthalmus, no squint eyes
No eye injuries, no redness, no black rings
Serous discharge present from eyes
 Nose
Mucosa: Pink and moist, Milia present
Septum: Medially located
Nasal breath: Both nostrils
No nasal discharges, bleeding, or crust
 Mouth
Lips: Normal, Pink in colour, no cleft lip
Teeth: Absent
Gums: Normal, pink in colour, no signs of gingivitis
Tongue: Normal, No tongue tie, no white patches, no cyanosis
Uvula: Pink and motile
 Ear
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 Hearing acquits: Responds to voice
No ear discharge, no tenderness
 Neck
Length: Short
ROM: Yes
No swelling, stiffness or torticollis
 Chest
Inspection: Normal shape, no scars, no rashes. Chest rise with air entry. No retractions seen
Palpation: No mass or nodule palpable. Breast buds palpable
Percussion: Resonant sounds heard
Auscultation: Normal breath sounds heard
 Abdomen
Inspection: Normal contour, Symmetric, Umbilicus healthy, no rashes, no scars
Auscultation: Bowel sounds present in each quadrant
Percussion: No fluid and gas distention
Palpation: No organomegaly, no palpable mass
 Back
Body curves: No spina bifida, no scoliosis, lordosis or kyphosis
Movement: Showing ROM
Extensive lanugo present over scapular region and shoulders
No lesions, no lumps, no scars seen
 Extremities
Range of motion: Able to perform
Length: Equal
No. of digits: Normal, no polydactyle, no syndactyle
Nail color: No clubbing, no spoon shaped nails
Capillary refill time: <3 sec
No club foot, no injuries present
 Pelvic and genitalia
Female genitalia: Normal, Labia minora not fully covered by labia majora. No pseudomenstruation.
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SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM
Inspection: B/L chest rise with air entry. No paradoxical chest movements. No scars, no rashes. No tachypnea.
Some subcoastal retractions seen.
Palpation: No palpable mass or lymph nodes.
Percussion: Resonant sounds heard over lung fields but hyper-resonant sounds at the base.
Auscultation: B/L air entry present. Grunting sounds heard over lung bases on stethoscope.

CARDIOVASCULAR SYSTEM
Baby hemodynamically stable. Mean BP of 47mmHg without inotropes. Capillary Refill Time <3sec.
S1 and S2 heard normally.

ABDOMINAL EXAMINATION
Inspection: Normal contour, Symmetric, Umbilicus healthy, no rashes, no scars.
Auscultation: Bowel sounds present in each quadrant
Percussion: No fluid and gas distention. Dull sounds heard
Palpation: No organomegaly, no palpable mass. Abdomen soft and non-distended

GENITO-URINARY SYSTEM
Able to pass urine and stools. No pseudomenstruation

CNS
Conscious. Baby active. Semi flexed posture. Consolable cry.

SUMMARY OF PHYSICAL EXAMINATION

 Baby is preterm so all anthropometric measurements are less.
 Skin color is Plethoric
 Serous discharge from eyes present.
 Grunting sounds heard with stethoscope.
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ASSESSMENT OF GROWTH AND DEVELOPMENT:
Reflexes
Name of Reflex Baby’s Response Inference
Laughing/Sneezing/Coughin Spontaneous Normal and present
g
Sucking Able to initiate sucking but could not Present but could not sustain for
sustain it for long long
Rooting Turns head towards the stimulated Normal and present
side and opens mouth wide open
Gagging Immediately returns undigested milk Normal and present
Palmer grasp Grasps my little finger by closing her Normal and present
fingers around it
Moro reflex Symmetric abduction and extension of Normal and present
arms and legs with fanning of fingers.
Extrusion reflex Avoids ingesting milk and pushes Normal and present
spoon out with tongue
Swallowing Able to swallow milk Normal and present
Yawning Spontaneous Normal and present
Glabella Blinks eyes when glabellar region is Normal and present
tapped
Blinking Closes eyes in protection Normal and present
Babinski Fanning of toes when sole of the foot Normal and present
is stroked

Investigations:
Investigation Patient value Normal value Remarks
Hb 19.4 14-20 g/dl Normal
RBC 5.42 4.2-5.5 million/µL Normal
WBC 13.09×103 4000-11000 cells/µL Increased
Neutrophils 44.8% 60-80% Normal
Lymphocytes 38.4% 20-40% Normal
Monocytes 12.7% 2-10% Increased
Eosinophils 2.8% 1-6% Normal
Basophils 1.3% <2% Increased
Platelets 3.6 1.5-4 lakhs/ µL Normal
Direct serum bilirubin 0.71 <0.4 mg/dl Increased
Total serum bilirubin 7.96 1.4-8.7 mg/dl Normal

Blood Gas Analysis:

Parameter Patient value Normal value Inference
pH 7.452 7.35-7.45 Normal
pCO2 35 35-45 mmHg Normal

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 HCO3 25.1 22-26 mEq/L Normal
Na+ 126 135-145 mEq/L Decreased
K+ 4.4 3.5-5.1 mmol/L Normal

Blood Culture and Sensitivity

Sterile

Drug Profile
Medication Dose Route Action Indication Contra- Side effects Nursing Responsibilities
/Freq indication
uency
Inj. Piptaz 100mg IV/BD Broad Abdominal Hypersensitivity Diarrhea Drug interaction with warfarin,
(Piperacillin spectrum infection Known allergy to Nausea vecuronium, methotrexate.
and antibiotic. Soft tissue cephalosporin, Anemia Look for signs and symptoms of
Tazobactum) Inhibits infection monobactum, Candidiasis phlebitis
bacterial Pneumonia carbapenem Rashes Check for stool consistency
cell wall Phlebitis Check for levels of Hb and RBCs
synthesis.

Inj. 145mg IV/48 Aminogly Neonatal Hypersensitivity Ototoxicity Check for allergic reaction to sulphite
Amikacin hourly coside. Sepsis Chronic kidney Nephrotoxicity Check for urinary output
Inhibits Meningitis disease Nausea Check for ototoxicity or signs of
bacterial Recurrent Vomiting decreasing hearing acquity
protein Urinary tract Loss of appetite Maintain adequate hydration
synthesis infections Vertigo Maintain intake output chart
by binding
to 30S or
50S
ribosomal
subunit

Inj. Caffeine 10mg IV/O CNS Apnea of Necrotizing Restlessness Interaction with theophylline,
D stimulant. prematurity enterocolitis Tachycardia cimetidine and ketoconazole
Acts as Chronic liver Poor feeding Dilution with dextrose solution
selective disease Rashes Check for respiratory status
adenosine Cardiac Lethargy Monitor the baby for apnea
antagonist arrhythmias Bloating Check for liver function
at A2a
receptors
and
modulates
many
neurotrans
mittors

Nursing Diagnosis
1. Impaired gas exchange related to deficiency of surfactant secondary to premature birth as evidenced by
tachypnea and grunting sounds.
2. Imbalanced nutrition: less than body requirement related to increased work of breathing as evidenced by
low birth weight.

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 3. Interrupted family process related to child’s hospitalization as evidenced by disruptive family interaction
with the baby.
4. Disorganized infant behavior related to environmental stimulation as evidenced by alterations in heart
rate and respirations.
5. Risk for infection related to prematurity and respiratory disease.
6. Risk for impaired thermoregulation related to premature birth.
7. Deficient knowledge related to care of low birth weight and premature baby as evidenced by
communication pattern of mother.

Assessment Diagnosis Goal Planning Implementatio Evaluation

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Episodes of Impaired gas Baby will -Assess the -Respiratory Baby is able to
tachypnea, exchange related to remain free respiratory status including maintain clear
restlessness deficiency of of signs of status of the respiratory rate, lung fields and
surfactant secondary respiratory neonate. rhythm and is able to
to premature birth as distress and depth is maintain
evidenced by maintain assessed. saturation of
tachypnea and saturation 95%.
grunting sounds. above 92%. -Assess -Oxygen
oxygen saturation is
saturation. assessed
continuously
with the help of
pulse oximeter.
SpO2 level is
maintained
between 93 to
97%.

-Give proper -Propped up

position. position given

-Suction as -Suctioning is
required. done as and
-when required.

-Assess for -Baby is put on

need of CPAP with FiO2
additional of 21% and
ventilation PEEP of 7cm of
source. H2O.

-Assess the -Baby is

baby for continuously
alterations in assessed for
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 behaviors. behavioral
alterations
secondary to
hypoxia.

-Administer -Inj. Caffeine

ordered 10mg OD
medication through IV route
is given.

Assessment Diagnosis Goal Planning Implementatio Evaluation

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Increased Imbalanced Child will be -Monitor the -Baby’s weight Baby is able to
work of nutrition: less able to take weight of the is assessed on tolerate the feeds
breathing than body adequate feeds baby daily. daily basis. as prescribed by
Feed requirement as prescribed the physician.
intolerance related to by the -Give -Propped up
increased work physician. comfortable position given
of breathing as position during during feeding
evidenced by and after and right lateral
low birth feeding. position is given
weight. after feeds.

-Maintain a -Clean and

clean odour free
environment environment is
around the provided.
child.

-Measure -Abdominal
abdominal girth is
girth. measured.
AG=23cm.

-Give small and -Small and

frequent frequent
feedings. feedings of
EBM @ 15ml/2
hourly given.

-Provide -Parenteral
parenteral nutrition in the
nutrition as form of TPNand
prescribed. Interlipid is
given.

-Monitor the -Baby is

baby for signs monitored for
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 of feed signs of feed
intolerance. intolerance and
vomiting
continuously.

Assessment Diagnosis Goal Planning Implementatio Evaluation

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Fear of mother Interrupted Family will -Assess anxiety, - Anxiety, fear Mother is able
to handle the family process express major fear, erratic and perception to express her
baby related to stressors behavior, of crisis fears, anxieties
child’s accompanying perception of situation is accompanying
hospitalization infant’s ailment crisis situation assessed. Mother infant’s ailment.
as evidenced by family is quite anxious
by disruptive member. about care of
family preterm infant.
interaction
with the baby. -Mother is
-Encourage encouraged to
verbalisation of verbalise her
feelings and feelings.
questions.
-Mother’s
-Accept the feelings and
feelings and fears are
fear in a non accepted without
judgemental being
manner. judgemental.

-Psychological
-Provide support to the
psychological family is
support to the provided.
family.
-Mother is
-Involve mother involved in the
in the care of care of newborn.
newborn.
-Mother is
encouraged to
-Encourage visit the infant
open visitation. and provide
KMC.

-Mother’s effort
in caring for
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 -Provide infant is
positive recognised and
feedback and appreciated.
recognise
family efforts in
caring for infant

HEALTH EDUCATION:
Mother is educated regarding care for low birth weight baby. She is encouraged to provide KMC to the baby
and during KMC she should try to initiate breast feeding to the child. She is encouraged to feed the baby
through OG tube and talk to the baby while feeding. She is also encouraged to take the baby in her lap and
cuddle the baby. She is educated to give the baby only her breastmilk and also educated about maintaining
appropriate body temp. of the baby. She is encouraged to take bath before giving KMC to the baby and continue
KMC practice for minimum of 2 hours continuously. She is educated about general danger signs and when to
see a doctor. She is educated to burp the baby adequately after breastfeeding or Katori spoon feeding.
SUMMARY:

B/o Meenakshi, 14 days neonate was admitted to NICU with complaints of low birth weight, prematurity,
feeding intolerance and respiratory distress. Initially she was put on CPAP and started on IV fluids. Gradually
she was weaned off from CPAP to room air and from IV fluids she was started on OG feeds and Gradually
Katori spoon feeding was initiated. The baby was improving well and gaining adequate weight. Mother was
also gradually involved in caring for the baby and KMC was also initiated. It was a good case and I was able to
learn many things from this case.

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