Question

Please give mom

1 Educational  Nsg Dx

2 Goal/outcome

4 Intervention and rationale

2 Evaluation

For a 3 weeks old infant born at 35 weeks gestation with upper respiratory infection with symptoms of temp. 101, cough/congestion.

Answer 1

Impaired gas exchange related to alveolar capillary membrane changes.

Goals-The newborn will remain free of increasing signs of respiratory distress.

Nursing interventions   

Monitor temperature,respiratory rate ,depth,and effort,including use of accesory muscles,nasal flaring and abnormal breathing patterns.

Rationale-All the above mentioned may be signs of infection.

Monitor oxygen saturation continiously using pulse oximetry

Rationale-An oxygen saturation less than 90% indicates significant oxygenation problems.

Administer antipyretics as per doctors order.

Rationale-to reduce fever.

Observe for cyanosis of the skin,especially note the color of tongue and oral mucus membranes.

Rationale -central cyanosis of the tongue and oral mucosa is indicative of serious hypoxia and is a medical emergency.

Evaluation:Outcome was met,partially met or unmet