NURSING CARE PLAN FOR PREMATURE NEWBORN

STUDENT: Hans MEZA TORRES, Celina BARZOLA ORTEGA, Margot TORRES SIMEON, Marvin PUCHOC VALENTIN
TEACHER : Jheysen BALDEON DIEGO

CASE: Premature neonate of 36 weeks of gestation and weight of 1600 g, height of 40 cm, head circumference of 32 cm, chest
circumference of 30 cm and abdominal circumference of 31 cm presents with generalized cyanosis, abnormal respiratory patterns, low
muscle tone and less activity (Apgar at one minute 4 pts. and at 5 minutes 6 pts.), he is hospitalized in the NICU with oxygen therapy and
strict monitoring of vital functions.

DEGREE
MONITORING
NURSING OF
GOAL NURSING INTERVENTIONS COMPLICATIONS INDICATORS
DIAGNOSIS DEPENDE
OR RESULTS
NCY
DOMAIN : 02 1) Start orogastric 1) Washing hands before  neurological damage GRADE III The NB
Nutrition tube feeding with handling the RN using  Hypoxia Totally tolerates BF
BF as early as appropriate technique  Hypoglycemia dependen through an
CLASS: 01 possible. 2) Place a SOG for feeding.  Hyperbilirubenia t orogastric
Ingestion 2) Achieve a 3) Observe abdomen,  Hypovolemia tube.
CODE: 00002 weight increase presence of hydro-aerial  hypovolemic shock
between 10 - 15g sounds. The RN
Nutritional per day. after 4) Control weight, head manages to
imbalance: intake starting feeding circumference growth and gain weight in
less than needs r/c with LM. height. 5 days with BF
inability to eat food 5) Start enteral feeding of BF through an
m/p pale mucous with 263 mg/day orogastric
membranes and 6) Observe characteristics of tube and has
intake less than the the gastric content, if it is gained 75 g.
recommended greater than 30% of the
daily amounts. total volume administered
or is greenish, yellowish, or
bloody, suspend feeding.
7) Perform partial balance of
income and expenses
DOMAIN : 11 1. Maintain the 1. Washing hands before Neurological disorders GRADE III  The NB is
security/protection neonate's body handling the RN using  Cardiovascular disorders Totally maintained
temperature appropriate technique (progressive decrease in dependen with a
CLASS: 6 within the 2. Place the RN under radiant blood pressure) t temperature
thermoregulation normal ranges heat or incubator.  Lung disorders range
36.5ºC to 37ºC 3. Monitor temperature (bradypnea due to between 36.5°
CODE: 00008 2. Prevent (36.5ºC to 37ºC) depression of the to 37° C at the
hypothermia. 4. Wrap the NB with respiratory center) axillary level.
Ineffective 3.Achieve a neutral transparent plastic to avoid  Alterations in the acid-  The NB is in
thermoregulation thermal heat loss due to evaporation, base balance (for every the incubator.
r/c extremes of life environment and this also makes it easier 1ºC of temperature
(NB at 36 weeks of where the ambient to observe it. below 37ºC, the pH
gestation) m/p temperature 5. Maintain humidity at 50% increases by 0.0147, the
generalized fluctuates between or higher in incubator or PaO2 decreases by 7.2%
cyanosis 24° C to 28° C heater to reduce heat loss and the PaCO2 by 4.4%.
4. Avoid insensitive through evaporation.  Kidney disorders
losses 6. Cover with a hat to (Hypothermia is usually
prevent heat loss from the accompanied by a
RN. generally mild degree of
7. Prewarm objects kidney failure, with
(blankets, covers, etc.) slight increases in urea
located near the RN and creatinine levels)