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.

Answer 1

1.Nursing Diagnosis

Impaired gas exchange related to immature lungs as evidenced by hypoxia,increased respiratory rate secondary to preterm birth

Goal /outcome

To maintain normal oxygenation without oxygen support

Baby is able to breath normally

Nursing intervention and rationale

• Administer oxygen to relieve hypoxia
• Monitor vital signs tpevery hourly to get the base line data and plan for care
• Position the baby in head elevation status as this can increase the lung capacity
• Administer medication as per order to enhance breathing
• Provide oral care as dryness of mouth is expected if there is any mouth breathing

2.Risk for aspiration related to breast feeding as evidenced by preterm birth and decrease in reflexes

Goal/Outcome

Baby shoukd be able to take breast feed without any problems

Nursing intervention and rationale

• Check for the order of the pediatrician to proceed for breast feeding
• Teach the mother about the breast feeding techniques
• Encourage the mother to feed the baby with syringe or bondla first with expressed breast milk,to initiate the sucking reflex.
• Provide feeding in propped up position ,to prevent regurgitation
• Ensure the mother burps the baby to relieve the gas