Question

A newborn baby has the two following nursing diagnoses:

Impaired gas exchange related to premature birth as evidenced by 70 to 80 breaths per minute

Risk for Aspiration

For each of the above diagnosis, please provide 5 nursing interventions and the rationales:

to lower the newborn's breathing rate to 39 to 60 breaths per minute

and

to maintain a patent airway and clear lung sounds

Thank you.

Answer 1

Nursing Diagnosis :

A).Impaired gas exchange related to premature birth as evidenced by 70 to 80 breathes per minute.

Nursing Interventions

1) Position to facilitate airway expansion and prevent collection of secretions(prone position may be preferred in preterm infant to increase chest expansion and oxygenation.

Rationale: To allow oxygen entry into bronchial tree and alveoli.

2) Closely monitor for deviations from desired breathing pattern check the pulse oximetry,arterial blood gases, clinical signs of poor oxygenation, grunting,nasal flarring, apnea, tachypnea, retractions,cyanosis.

Rationale: To facilitate oxygenation by implementing appropriate therapy such as supplemental oxygen, mechanical ventilation, or change of position.

3) Monitor vital signs for change in condition or status such as decreased cardiac output(poor perfusion , mottling,deteriorating ventilation status)

Rationale: To implement appropriate therapy such as suctioning,supplemental oxygen or vasopressor drugs.

4) Assist with exogenous surfactant administration and monitor patient tolerance or change in status.

Rationale: To increase alveolar expansion and exchange oxygen and carbon dioxide exchange.

5) Suction oropharynx,nasopharynx,trachea, or endotracheal tube only as necessary and based on respiratory assessment.

Rationale: To remove secretions that may interfere with adequate ventilation and oxygenation.

B)Risk for Aspiration

Nursing Interventions

1)Suction hypopharynx at birth.

Rationale:To maintain patent airway.

2) Intubate and suction trachea (as needed).

Rationale: To remove excess secretion which may lead to aspiration.

3) Monitor for respiratory distress; manage with supplemental oxygen.

Rationale:To further prevent the newborn with complications.

4) Position newborn in upright or prone position while feedings.

Rationale;It prevents aspiration.

5) Burp the baby after every feed if possible.

Rationale: To prevent aspiration.