Question

Baby M is a patient who was born yesterday at 35 weeks gestation. Baby M’s mother had a history of severe preeclampsia during pregnancy, and was induced at 35 weeks for uncontrolled hypertension. Baby M weighs 1600 Gms, which is under the 5th percentile on the growth charts. Baby M is being treated for Respiratory Distress Syndrome, secondary to prematurity. Baby M is currently under a radiant warmer and is receiving humidified oxygen 30% at 2L/min via nasal cannula. The vital signs are as follows: temperature- 98-99 F, heart rate-150-160 beats per minute, respirations- 70-80 breaths per minute, Oxygen saturation 88% on room air/ 96% on 30% oxygen. Baby M is currently NPO and is receiving an IV of Dextrose 10/water at 7mL/hr. Mom plans to breastfeed the baby.

Using your NANDA-I book, choose one actual nursing diagnosis and one “Risk for” diagnosis for this client.

             Describe a nursing intervention, the rationale for choosing the intervention, and a nursing outcome for each NANDA-I diagnosis.

             Remember that Nursing Outcomes must be measurable and contain a time frame for completion.

Thank you.

Answer 1

ANSWERS :

1. NURSING DIAGNOSIS : Impaired gaseous exchange related to immature lungs of newborn

- Risk for infection related to prematurity

- The current nursing diagnosis for  Respiratory distress syndrome

2. NURSING INTERVENTIONS :

* To maintain normal breathing

RATIONALE :

- * Decreases anxiety in the mother

NURSING OUTCOME :

* Breathing pattern is improved