Nb Nursing Diagnosis

Nursing Diagnosis: Ineffective Thermoregulation R/T newborn transition to extrauterine life Ineffective Thermoregulation R/T immature compensation for changes in environmental temperature. High Risk for infection R/T maturational factors, immature immune system Risk for Infection R/T break in skin integrity at umbilical cord site Risk for Altered Nutrition (more or less than body requirements) R/T (insufficient caloric intake or excessive caloric intake) Ineffective Airway Clearance R/T excessive oropharyngeal mucus Prevent infection: handwashing, stay away from large groups or ill individuals, prophlactic agents (EES, cord care, bathing) Vernix Breastfeeding Warmth Bath after temperature is stable warmer/isolette/bundle hat keep out of drafts skin to skin Position of sleep/prevent SIDS Back to sleep feet to foot of bed no stuffed animals or excessive blankets in bed don’t cover head in stroller don’t keep house too warm No smoking around infant Cleanliness No tub baths until cord off and healed clean around organs of elimination and mouth after soiling to prevent skin break down daily head to toe bath not necessary OK to clean and touch the “soft spot” fold diapers away from umbilicus NEVER leave child alone in tub!! Circumcision-After Care keep wound clean and dry (warm water) ck urination w/in 12 hrs after procedure monitor for bleeding s/s of infection will not occur immediately after procedure Diagnosis IMPAIRED GAS EXCHANGE related to inadequate surfactant levels; as evidenced by grunting, flaring, substernal and intercostal retractions, CO2 50 and pH 7.31 per CBG and CXR with ground glass appearance suggestive of hyaline membrane disease. I - Administered warmed and humidified oxygen at rate ordered per oxyhood, wean slowly to room air as ordered. - - Monitor and document hourly Fi)2 levels per calibrated O2 analyzer. Sa)2 per pulse oximeter, and vital signs (temperature, heart rate/rhythm, respiratory rate and effort). - - Auscultate lung fields hourly and assess respiratory effort hourly, cyanosis, grunting, flaring or retracting and activity. - - Maintain gastric decompression per oral gastric tube open to air, perform oral/nasal suctioning and chest physiotherapy as ordered. - - Maintain temperature in normal range and schedule nursing interventions to help newborn minimize stress, conserve energy, and reduce oxygen requirements.

- - Assess hourly for continued improvement and readiness to wean from oxygen therapy, as well as, signs of worsening condition. INEFFECTIVE THERMOREGULATION related to prematurity and low birth weight; as evidenced by poor flexion and lack of subcutaneous fat stores needed for non shivering thermogenesis. I -- Provide neutral thermal environment per radiant warmer with temperature probe secure and in anterior position to newborn. - - Protect newborn from loss of body heat from conduction, convection, radiation, and evaporation. - - Cover warmer bed over infant's chest and lower body with saran wrap to prevent insensible fluid loss and drafts. - - Monitor axillary temperature hourly and adjust settings on warmer as needed to maintain temperature of 97.8 to 98.8 F. - - Warm and humidify oxygen being delivered to newborn. ALTERED NUTRITION: LESS THAN BODY REQUIREMENTS related to respiratory distress; as evidenced by confinement under oxyhood, oral gastric tube to drainage, respiratory rate greater than 60 per minute, and NPO status I - - Provide IV fluids, D10W for hydration and glucose while newborn is under oxyhood. - - Assess need for parenteral nutrition if oxygen therapy is longer than 12 hours. - - When respiratory status has stabilized begin feeding newborn D5W to assess tolerance to oral feedings. Begin formula feedings after two glucose water feedings. - - If newborn does not have a strong sucking, gag, or swallow reflex or is at risk for aspiration, provide feedings through a nasogastric (NG) tube. - - Monitor glucose levels hourly until stable, each four hours times two, then every eight hours while on IV fluids.