MEDICAL DIAGNOSIS: Prematurity NURSING NEED: Oxygen PRORITY NO #: one

ASSESSMENT DATA NURSING PATIENT’SOBJECTIVE INTERVENTIONS RATIONALES EVALUATION

DIAGNOSIS
SUBJECTIVE/OBJECTIVES

Objective Data: Ineffective Neonate will maintain an 1 Elevate Cot in a 1.To facilitate adequate Patient was able

breathing effective breathing pattern tripod position ventilation and chest to maintain an
Grunting intermittently
pattern related following nursing and expansion. effective
(Nurseslab.com
3 liters of Oxygen via nasal
to immaturity collaborative management breathing
2017) (Nurseslab.com 2017)
cannula.
pulmonary as evidenced by neonates pattern
2.Monitor spo2 and 2.To determine the
use of accessory muscles, functioning respiration being reduced following
Respiratory rate effectiveness of the oxygen
secondary to from 62 bpm to 60 bpm, nursing and
Sp02 88%
every 15minutes therapy and
premature an increased in Sp02 from collaborative
R 62bpm medication.(Nurseslab.com
state as 88% to 90% within eight management as
2017)
evidence by hours. evidenced by
3.. Maintain patient
Grunting 3..Oxygen administration patient
on 3 litres of
intermittently, has been shown to correct respiration
humidified oxygen
low oxygen in blood which being reduced
utilizing 3
causes shortness of from 62 bpm to
litres of
Oxygen via (Nurseslab.com breath.(Nurseslab.com 60 bpm, an

nasal cannula, 2017) 2017) increased in

the use of Sp02 from

accessory
88% to 90%
4. Provide 4.Beta-adrenergic agonist
muscles,
within eight
respiratory medications relax airway
Sp02 88% hours
medications per smooth muscles and cause

And R doctor’s bronchodilation to open air

62bpm order(Nurseslab.com passage.

2017)
(Nurseslab.com 2017)
MEDICAL DIAGNOSIS: Prematurity NURSING NEED: Nutrition PRORITY NO #: two

ASSESSMENT DATA NURSING PATIENT’SOBJECTIVE INTERVENTIONS RATIONALES EVALUATION

DIAGNOSIS
SUBJECTIVE/OBJECTIVES

Imbalanced Neonate will demonstrate . Assess for Maturity The nurse will be able The neonate
Nutrition: Less and maintain steady reflex with regards to determine the should display
Subjective: than Body weight gain at least 20- appropriate method of progressive
to feeding(e.g
Requirements 30g and also maintain feeding for the infant. weight gain
related to the sucking, swallowing toward goal
normal growth pattern
neonate’s low and cough) (Doenges, Marilynn E. within 24 hours
after 12-24 hours of et al 2010)
birth weight, continuous nursing and of continuous
Objective: On assessment the small stomach (Doenges, Marilynn nursing and
neonate is small for gestational collaborative intervention
capacity E. et al 2010) collaborative
age, lying in a supine position, secondary to intervention
crying and yawning prematurity as
intermittently. Frenulum is evidenced by
short. Neonate is attached to weak feeding
Nasal cannula receiving 3L of reflexes and
Oxygen and an IV access is inability to
attached to baby’s right hand tolerate
where baby is receiving 30mls feeding for at 2. Auscultate the
of 5% Dextrose Normal Saline. least 10 presence of bowel
minutes. Diminished or
sounds, assess
hypoactive bowel
physical status and sounds may reflect
respiratory decreased
status.(Doenges,
Marilynn E. et al gastric motility and
2010) constipation (common
complication)
related to limited fluid
intake, poor food
choices, decreased
activity, and
hypoxemia.(Doenges,
3. Assess the weight Marilynn E. et al 2010)
by measuring the
body weight every
day, then document
in infant growth
.
charts.(Doenges,
Marilynn E. et al The nurse will be able
2010) to identify the risk and
the degree of risk to
4. Provide frequent growth. (Doenges,
small feedings. Marilynn E. et al 2010)
(Doenges, Marilynn
E. et al 2010)

5. Assess the Provides opportunity

hydration, note the
to increase total caloric
fontanels, skin intake and reduces
turgor, urine specific fatigue. (Doenges,
gravity, the Marilynn E. et al 2010
condition of the
mucous
membranes, weight
fluctuations.
.(Doenges, Marilynn Increased metabolic
E. et al 2010) needs of the neonate
may increase fluid
requirements. Infant
state of hyperglycemia
6. Monitor can lead to dieresis in
laboratory tests as infants. Increased
indicated: serum demands of intravenous
fluids might be needed
glucose, blood urea
but must be carefully
nitrogen, and monitored to prevent
creatinine. fluid overload.
.(Doenges, Marilynn .(Doenges, Marilynn E.
E. et al 2010) et al 2010)

Hypoglycemia can
occur in the early 3
hours of birth.
Glycogen stores can
quickly reduce and
gluconeogenesis
becomes inadequate.
Detecting changes in
the renal functioning
associated with a
7. Position the baby decrease in deposits of
for feeding nutrients and fluid
levels due to
malnutrition.
.(Doenges, Marilynn E.
et al 2010)

This reduces the risk of

asphyxiation and
promotes better
receival of milk
especially given the
short Frenulum.
MEDICAL DIAGNOSIS: Prematurity NURSING NEED: Safety and Security PRORITY NO #:three

ASSESSMENT DATA NURSING DIAGNOSIS PATIENT’SOBJECTIVE INTERVENTIONS RATIONALES EVALUATION

SUBJECTIVE/OBJECTIVES

Risk for infection related Neonate will remain free perform hand This method At the end of the
to compromised immune from infection, as hygiene before and prevents the 12 hours shift
Objective: system secondary to evidenced by normal the neonate was
after attending to transmission of free from any
prematurity vital signs throughout the
On assessment of premature neonate contact microorganism signs of infection
12 hours shift following
Neonate, neonate was seen with nursing and collaborative from nurse to and all
iv access to right and umbilicus care. neonate. interventions
clamped were successfully
Don the proper carried out.
PPE.
Barrier device
which act as a
preventive
measure from
transferring
microorganisms
nurses uniform
to clothing to
baby
Ensure that if the This will protect
neonate receives the neonate
expressed breast against
milk the milk is infections, in
stored in sterilized particular
container. diarrhea and
vomiting.

Ensure the cot of

the baby is cleaned This reduces
with the correct the buildup of
cleaning agents to microorganism
eliminate on the cot of
microorganisms. the baby.

Diapers
absorbs urine
Ensure that the
and moisture
diaper of the
from the stool
neonate is checked
of the
and changed every
neonates,
two hours.
having such
environment it
is a good
breeding
ground for
 microorganism
thus changing
the diaper
reduces the
chance of
buildup of
microorganism
which may also
cause a
breakdown in
the integrity of
the skin.

Clean Umbilicus
with sterile cotton
Prevention of
and 70% white
infection.
alcohol three times
daily.

Ensure area
around IV access is
cleaned

Prevention of
infection.