Aquilei, }essah S.

BSN E RLE uioup

Initial of the Patient: Bb. X Age: NICU-BMC
Physician: Dr.
NURSING CARE PLAN
ASSESSMENT NURSING
DIAGNOSIS
RATIONALE GOAL OF CARE NURSING INTERVENTION RATIONALE EVALUATION
Pt`s History:
-preterm neonate

Objective Data:
Use oI accessory muscles to breath
%achypnea RR73
%achycardia CR162
!olycythemia
CBC revealed elevated Hct, MCV, MCH
Hct: 0.5617 (normal range 0.37-0.54)
MCV: 118.4 (n.r. 82-98)
MCH: 36.69 (n.r. 33-36)

Impaired gas
exchange related
to decreased
number oI
Iunctional
alveoli and
deIiciency oI
surIactant
secondary to
prematurity
Lung surIactant
(lipoprotein
mixture that cover
the alveoli
reducing surIace
tension oI
pulmonary Iluids)
does not Iorm in
adequate amounts
until about 34
th
to
35
th
week oI
pregnancy.
Inadequate lung
surIactant leads to
alveolar collapse
with each
expiration. %his
leads to poor
pulmonary
Iunctioning
resulting to
impaired gas
exchange.

AIter 8 hours oI
nursing intervention,
inIant will exhibit
signs oI adequate
oxygen supply

Monitor and record the vital
signs every hour


bserve Ior changes in
respiratory rate and pattern,
breath sounds and airway
patency; grunting, nasal
Ilaring, retractions, and
cyanosis
!osition in prone or supine,
avoiding neck hyperextension







Reposition every 2 to 3 hours


Administer oxygen supply via
Iace mask at L/min
Maintain a neutral thermal
environment. !lace under
droplight iI the body
temperature is less than 36.5 C.

%o obtain baseline data and to
monitor and evaluate
pulmonary and circulatory
status
%o detect signs oI respiratory
distress




%o promote optimum air
exchange; in preterm inIant, the
prone position increases
oxygenation and lung
compliance and decreases
energy expenditure; supine
position should be used Ior
sleep when inIants have
recovered enough to tolerate it
%o help dependent areas oI
lungs drain into the main
bronchi
%o give 2 support and
maintain oxygen saturation
%o conserve energy use by
preventing increase in energy
demand








Aquilei, }essah S. BSN E RLE uioup
Initial of the Patient: Bb. X Age: NICU-BMC
Physician: Dr.
NURSING CARE PLAN
ASSESSMENT NURSING
DIAGNOSIS
RATIONALE GOAL OF CARE NURSING INTERVENTION RATIONALE EVALUATION
Objective Data:
Hypothermia %emp:34.6
Cool skin
%achypnea RR:72
IneIIective
thermoregulation
related to
immature
thermoregulation
center, less Iat
and thin skin
%he temperature
control center oI
the brain oI
preterm inIants is
less mature and
less Iunctional.
%he skin is thin
with blood vessels
near the surIace,
and little
subcutaneous
white Iat is
present to serve as
insulation. As a
result, heat loss is
rapid. %he shorter
time in the uterus
allows less brown
Iat to accumulate,
impairing inIant`s
ability to produce
heat by
nonshivering
thermogenesis.

AIter 8 hours oI
nursing intervention,
inIant will exhibit
maintenance oI
stable body
temperature within
the normal range
(36.5-37.2C)

!lace under droplight

!ut a blanket over the inIant



!lace knitted or cloth cap on
head
%ake axillary temperature
every hour



Monitor Ior signs oI
hyperthermia (Ilushing,
tachycardia, altered LC) and
hypothermia (decreased
activity, respiratory distress,
cool mottled extremities)



Avoid inIant exposure to cool
air, cold stethoscopes and
prolonged bathing
Monitor serum glucose levels
(HG%). II the blood glucose is
low, Ieed the neonate.
%o maintain stable body
temperature
It decreases convective heat
loss Irom exposure to draIts as
well as insensible and
evaporative water loss
%o prevent heat loss Irom
exposed scalp
%o detect necessity Ior
environmental temperature
regulation and to determine
inIant`s response to
environmental thermoregulation
%o prevent untoward eIIects oI
hyperthermia (Iluctuating
cerebral perIusion, apnea,
increased metabolism with
decreased available glucose Ior
vital Iunctions) oI hypothermia
(increased glucose utilization,
lactic acidosis, respiratory
compromise)
%hese predispose the inIant to
heat loss

onshivering thermogenesis
results in use oI glycogen
stores. Feeding provides
calories Ior heat production.







Aquilei, }essah S. BSN E RLE uioup
Initial of the Patient: Bb. X t Age: NICU-BMC
Physician:
NURSING CARE PLAN
ASSESSMENT NURSING
DIAGNOSIS
RATIONALE GOAL OF CARE NURSING INTERVENTION RATIONALE EVALUATION
Objective Data:
Hypothermia %emp:34.6
Cool skin
%achycardia CR: 162
%achypnea RR: 72
levated WBC & lymphocyte
WBC: 13.4 (normal range 4.8-10.8)
Lymphocyte: 53.8
(normal range 19-48)

InIection related
to immature
immune system
!reterm inIant
have a lowered
resistance to
inIection because
they have
diIIiculty
producing
phagocytes to
localize inIection
and deIiciency oI
IgM antibodies
due to insuIIicient
production.
AIter 8 hours oI
nursing intervention,
inIant will exhibit
no signs oI
nosocomial
inIection
(temperature
instablility, lethargy,
irritability, changes
in color,
cardiovascular
instability and
abnormal breathing
pattern)
Monitor vital signs Ior stability



o handwashing beIore and
aIter handling the neonate,
ensure all supplies or
equipments are clean beIore
use and ensure strict aseptic
technique with invasive
procedures
!revent contact with persons
who have communicable
inIections
Administer:
-Ampicillin -------
-Gentamicin----
Instability, hypothermia, or
prolonged temperature
elevations are indicators oI
inIection
%o minimize inIective
organisms





%o minimize inIection risk



Bactericidal action against
sensitive organisms and inhibits
synthesis oI bacterial cell wall,
causing cell death
Bactericidal: Inhibits protein
synthesis in susceptible strains
oI gram-negative bacteria;
appears to disrupt Iunctional
integrity oI bacterial cell
membrane, causing cell death