Question

Please give

1 Psychosocial Nsg Dx

2 Goal/outcome

4 Intervention and rationale

2 Evaluation

For a 3 weeks old premature infant with upper respiratory infection with symptoms of temp. 101, cough/congestion.

Answer 1

Nursing Diagnosis:

Ineffective thermoregulation r/t

to prematurity as evidenced by poor flexion &lack of subcutaneous fat.

Nursing Goal: After 24 hrs of thorough nursing intervention, pt will exhibit thermal homeostasis appropriate for age =36.5-37 C(axillary).

Nursing Intervention

*INDEPENDENT:

1. Assess V/S (esp T)2. Place infant in a warmer, isolette,incubator, or open bed with radiant warmer or open crib where ininfant also has appropriate clothing.3. Use heat lamps during certain procedures & warm objects coming in contact with the infants body such as clothing.

*COLLABORATIVE:

1. Provide or administer meds as prescribed.

Rationale:

-Hypothermia predisposes infant to cold stress, utilization of nonrenewable brown fat stores. Hyperthermia causes further respiratory depression instead of increased RR,leading to apnea &reduced O2 uptake.-Maintain thermoneutral environment, helps prevent cold stress.-Decreases heat loss to the cooler environment of the room.-Helps prevent seizures associated with hyperthermia

Outcome Criteria:  

After 24 hours of close monitoring,infant was able to establish normothermia and had

T=36.5 C

Actual Evaluation;  Goal was met, left patient lying on bed afebrile &with a temperature appropriate for age

Altered nutrition: less than body requirements r/t

to small stomach capacity & prematurity as evidenced by weak feeding reflexes &NPO status

After 24 hrs of continuous nursing intervention,pt will demonstrate steady wt gain in anormal curve (@least 20-30g/day)and also maintained growth.

*INDEPENDENT:

1. Assess presence of reflexes associatedwith feeding (i.eswallowing, sucking &coughing)2. Instill breast milkor formula slowly over20min @ a rate of 20ml/min.3. Initiate intermittentor tube feedings asindicted.4. Position infant onright side or pronewith HOB elevated @30 degrees.

*COLLABORATIVE:

1. Feed as frequentlyas indicated based oninfant’s wight &estimated stomachcapacity

-Determines the appropriate feeding method for the infant.-Too rapid entry of feeding into stomach may cause rapid rebound response with regurgitation, increased risk of aspiration & abd distension all of which compromises respistatus.-Gavage feedings may be necessary to provide adequate nutrition in infant who has a poorly coordinated suck-and-swallow reflex or who becomes fatigued during oral feedings.-Facilitates gastric emptying & prevents reflux.

after 24 hrs,pt was seen beside mother,exhibiting good suck-and-swallow reflex, and showed to have added 10g.