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190 ~TE~~~INF~T NURSING CARJ2 PLANS Assess for bladder disten- tion whenever hndd height is checked after childbirth. Encourage client to void every 2 to 3 hours after birth. Provide for privacy, assist client to bathroom if possible, or to sit on bed- pan, run water, pour watm water over perineum, etc. Measure amount voided until normal pattern is established. Monitor intake and output (specil Fy frequency). Assess for bladder disten- tion after each voiding until the client demon- strates ability to empty bladder completely. Catheterize, using sterile technique, clients who have a distended bladder and are unable to void, or have not voided within 4 hours &er birth. Reassess client in 2 hours and if still unable to void, insert a retention (foley) catheter as ordered. Administer antibiotics as ordered by caregiver (speci- fy: drug, dose, route, and times). Teach client to wash hands before and after using the bathroom and to wipe and apply peripads front to back. Assessment provides infor- mation about bladder dis- tention. A distended bladder inter- feres with uterine contrac- tion and may cause hern- orrhage (atony). Interventions may stimu- late micturation. Client should void at least 100 cc each time. Monitoring intake and output provides inforrna- tion about expected diure- sis and bladder emptying. Assessment provides infor- mation about bladder emptying. Bladder tone and sensation may return slowly after childbirth. Catheterization relieves bladder distention when client is unable to void. Sterile technique avoids introduction of microor- ganisms into the bladder. Retention catheter pre- vents bladder distention in clients who have not regained bladder sensation and tone. Caregiver may order antibiotics to avoid urinary tract infection. {Specify action of drug. } Teaching provides infor- mation the client needs to avoid the introduction of pathogens into the urinary tract. Inform client about post- partum diuresis and diaphoresis. Reassure client that Ip urine output is expected and that she shouldn't delay voiding. Information empowers the client to care for self with an understan~ng of puer- peral physiology. Frequent voiding prevents urinary stasis, which provides a medium for infection. Teaching ensures that the client will recognize signs of developing infection and seek appropriate med- icd care. Teach client the signs and symptoms of urinary tract infection to report to care- giver: frequency, urgency, burning or pain with uri- nation. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partial Iy met?) (Does client demonstrate ability to empty bfadder every 2 to 4 hours? Does client verbalize signs and symptoms of UTI to report?) (Revisions to care plan? D/C care plan? Continue care plan?) ~o~s~~~~o~, Risk fir Related to: Decreased muscle tone and GI motili- ty after childbirth, dehydration, fear of discomfort secondary to episiotomy, lacerations, or hemor- rhoids. God: Client will obtain relief from constipation by (datehime to evaluate). Outcome Criteria Client has an adequate bowel movement. Client verbalizes undersr~ding of need for fiber and flu- ids in her diet. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
~U~~~~~~ 131 INTERVENTIONS RATIONALES (Has client had an adequate bowel movement? Does client verbalize the importance of fiber and fluids in her diet to prevenr ~~nstip~~~on?~ Assessment provides infor- mation about normal Assess usual bow4 pattern and date of fast bowel moy~ent, Assess bowel sounds. Inform client that the bawds rend to be sluggish &er ~~ild~ir~ due to hor- monal inhences, 4 mus- cle tone, d~ydration, and the lack a€ food during labor. Reassure client that a bowef moment is not going to disrupt her stitch- Promote comfort of per- ineum and hemorrhoids by use of sitz baths, sprays, creams, err. as ordered (specify}. Instruct diem to stimulate bowel motility by eating fiber, €re& fraits and veg- erabfrs, drinking 8 to 10 gimes of fluids per day, and mild exercises such as walking daily Adm~n~ter stool sofreners as ordered (specify with nursing measures: e. g,. wirh a full g Iass of water). Evaluate effectiveness of stool sofiener Ispeci€y tim- ing). Adm~niste~ enema or sup- pository (specify) as es. bowel habits and current peristaltic activity. are plan?) Client may be expecting to have a daily bowel move- ment and become alarmed by any delay, (Revisions to care plan? DIC care pian? p on^^^^ Client may be fearful of damaging perineal inci- sions OE experiencing great pain with passage of stool, Sitz baths promote circula- tion, comfort, and healing (specify how specific spray, cream, etc. works). Client may be unkmiliar with information. Client may find new moti~t~o~ to improw diet and exer- cise in order KO prevent constipation. Specify action of ordered drug and rationale for nursing measures. Evduarion provides infor- mation about success of ~~Ke~ention. Specif+ action Q€pa~t~c~far type of enema or supposi- tory. Evduatian (Dadtime of evduarion of goal) (Has god been met? not met? parrialfy mer?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
192 MATERNALINFANT NURSING CARE PLANS Episiotomy and lacerations Crowning of perineal stretching ~Fetl Head\isiotomy unassisted midline or mediolate lubrication and spontaneous I I SUPPOfi delivery of head between contractions + lacerations extension 4 lacerations possible I 3rd degree 4 4* degree ral ? ? bleeding t pain | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
P~STP~TU~ 193 Puerperal Infeclion Bacterial infection of the reproductive tract during the postpartum period used to be called “childbed fever. ” This was the cause of significant maternal mortality and morbidity before the introduction of aseptic techniques and antibiotics. Uterine infection usually occurs at the placental site, the endometrium, and/or the myometrium, though it may spread resulting in pelvic cellulitis or peri- tonitis. The most significant sign of puerperal infection is fever greater than 100. 4' F after the first 24 hours. The accepted definition includes that fever is found on any 2 of the first 10 postpa~um days, when taken by mouth every 4 hours. The client may also experience malaise, anorexia, chills, abdominal pain, and slowing of involution. Lochia may be profuse, bloody, frothy, with a foul odor, or may be scant and nonoffensive. Elevation of WBC's is normal during the early puerperium. Fever may also result from respiratory complica; rims, breast engorgement or mastitis, throm- bophlebitis, pyelonephritis, and local wound abscesses (cesarean, vaginal, or perineal). When these causes are ruled out, puerperal infection is suspected. Risk Factors cesarean birth extensive vaginal or uterine manipulation multiple vaginal exams long labor, prolonged ruptured membranes intrauterine fetal monitoring chorioamnionitis retained placental fragments Medical Care A~inistration of broad-spectrum antibiotics (PO. or rv) CBC with sedimentation rate Urina~ysis Cultures Nursing Care Plans Infiction, Risk for (165) Related to: Spread of microorganisms from the reproductive tract. Pain (166) Related to: Inflammation and edema of reproduc- tive tract secondary to invading microorganisms. Defining Characteristics: Client reports pelvic pain (specify: abdominal tenderness, deep continu- ous pain, etc. ). Client rates pain (specify) on a scale of 1 to 10 with 1 being least, 10 being most. Client is (specifjc e. g., crying, grimacing, guarding abdomen, etc. ). Addillonal Diagnoses and Plans ~ar~~~~ Risk fir Ahered Related to: Delayed attachment secondary to maternal illness or discomfort. God: Client will exhibit appropriate parenting behaviors (by dateltime to evaluate). Outcome Criteria Client makes eye contact with infant; strokes, hugs, and talks to infant. Client states desire to care for infant. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
Assess attachment behav- iors recorded at birth. Note alterations, Validate findings with client (e. g., “You don't seem to have the energy to hold your baby now?”). Evaluate the possibility of cultural variation related to infant care res Fonsib~li~ (e. g., is Gr~dmo~her or sister caring for che baby!). Promote culturally relevant parenting activities through flexible visiting hours and acms to infant as desired by parents. Encourage client to share feelings about disruption of parenting. Offer emo- tional support and empa- thy. Promote sleep and rest by scheduling nursing care to avoid interruptions (sped- $)* Provide opportunities far the client to see and hold her baby. Provide photos and encourage phone calls if inht is restricted to nursery Role model infant care and appropriate parenting behaviors when inht is in room. Point out positive features and infant responses to sensory stimu- lation. Assessment provides infor- mation about the etiology a€ altered parenting to dis- tinguish between illness and psychological causes, Evaluation provides infoc- mation about the family's expectations related to infant care and “parenting” activities as defined by western European culture. Adjustment of hospital rules and routines should be made to promote fami- ly-mntered we. The nurse acts as client advocate. Client may experience guilt and depression because she is unable to care for her infant. Support assists client ta cope; empathy validates client's feelings. Rest is necessary ro pro- mote healing, Much nurs- ing care can be resched- uled. The mother and baby need opportunities to engage in the attachment process. Client may nor have expe- rienced appropriate moth- ering behaviors. Noting infant's features and responses facilitates attach- ment. Provide nonsedating pain relief before client holds or attempts to feed infmr. Assist client to feed her i&nt if possible or to pump breasts to maintain milk supply if unable to nurse (e. g., drug therapy), Encourage father or family to feed and care for the infint, in the ctient's room if possible, when the Client is unable to do so. Offer praise and positive feedback for effective par- enting behaviors. Perform infant assessments at client's bedside while providing information about the infant (e. g., reflexes, fontanels, behav- iors, etc. ). Make referrals as needed (specify: e. g,, social ser- vices, counsding, parent- ing groups), Pain or sedation may dis- uacr or decrease attention and interfere wirh attach- ment. Feeding the infant is a pri- mary parental task chat facilitates attachment and self-esteem. Many drugs cross into the breasr milk, Providing care and feeding promotes parenting skills. The client may observe care and offer parenting advice, Praise promotes self- esteem. Feedback provides information about effective behaviors. Assessment at the bedside provides the client wirh the opportunity to get to know her baby as an indi- vidual. Client may need addition- al help to parent effective- IF Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Does client make eye contact with infant? Does she touch and talk to her baby? Does diem report the desire to care for her infmt?) {Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POS~~TUM 195 Puerperal Infection Normal Vaginal Bacteria Bacteria deposited by vaginal exams internal monitoring 1 ruptured membranes lower uterine segment incision sites warm, moist environment blood and necrotic tissue 1 blood transport of bacteria septic peivic ~rom~p~ebitis bacterial &oliferation and colonization tissue invasion metritis myorietritis 1 parasketritis (pelvic cellulitis) ruptu of parametriai abscess lymphatic tr sport of bacteria-i pelitoniti S | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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POSTPARTUM 197- Venous Thrombosis The formation of blood clots in either superficial (SVT) or deep veins (DVT) is a potential compli- cation of childbirth. The term thrombophlebitis refers to thrombus (clot) formation due to inflam- mation of the veins, as in septic pelvic throm- bophlebitis. Emboli are clots that have detached from the vein wall and travel through the blood- stream. Pulmonary embolism describes the situa- tion when a clot lodges in the pulmonary artery. Complete occlusion of the artery results in severe respiratory distress and death. Puerperal physiolo~ that predisposes to thrombus formation includes increased clotting factors and platelets, decreased fibrinolysis, and release of thromboplastin from the placenta, membranes, and decidua. venous stasis: immobility history of thrombus formation varicose veins, heart disease, hemorrhage, anemia traumatic birth puerperal infection maternal obesity, advanced age, grand muitiparity Signs and Symptoms Pulmonary Embolism sudden onset respiratory distress: dyspnea, tachypnea, cough, rales, hemoptysis, chest pain, tachycardia, diaphoresis, pallor, cyanosis, feel- ings of impending doom-SVT more common with history of varicosities saphenous vein most common symptoms begin 3-4 days postpartum local heat, and redness along vein tenderness, firmness or bumps along vein DVT more common with history of thrombosis femoral vein, pelvic veins symptoms begin around 10 days postpartum cool, edematous leg: “milk leg” positive Homan's sign pain: foot, leg, inguinal, pelvic fever, chills, pale, Medical Care Pulmonary Embolism Respiratory support: oxygen Medications: IV heparin, streptokinase, and others surgical embolectomy SVT DVT bedrest with elevation support hose heart heat application analgesics prn heat strict bedrest with of leg above heart elevation of legs above application of moist Medications: IV heparin gradually converted to warfarin, analgesics, antibiotics if pyrexic Serial clotting studies: PT, PTT gradual return to ambulation with sup- port hose Discharged on war- farin (~ouma~in} | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
198 MATERNAL-INFANT NURSING CAW-PLANS N~~iflg Care Plans Related to: In Gammation and ischemia secondary to phlebitis. Defining Characteristics: Client reports pain in affected extremity {specify using quotes and a pain scale). Positive Homan's sign (specify extremity). Related to: Perceived threat to biologic integrity secondary to risk for pulmonary embolism. Defining Characteristics: Client expresses feelings of appreh~nsion (specify). Client is (specify: e. g., restless, tense, crying, etc. ). Purmgkgi Risk for Al..med (19. 3) Related to: Interruption of bonding process sec- ondary to maternal illness. Additional Diagnoses and Plans Injary, Risk for Related to: Venous obstruction, anticoagulant medications, risks for embolism. Defining Characteristics: None, since this is a potential diagnosis. Goal: Client wi Il not experience any injury by (dateitime to evaluate). Outcome Criteria Client's leg doesn't exhibit pain, pallor, redness, or edema. Bilateral pedal pulses are equal. No signs of respiratory distress: dyspnea, tachypnea. Client doesn't experience abnormal bleeding: bleeding gums, bruising, petechiae, or hematuria. kss client's vls and lower extremities for color, temperature, edema, and tenderness (Woman's sign) q 8h. Instruct client to maintain bedrest with legs elevated as ordered {specify). Avoid massaging aected feg. Maintain warm, moist heat to affected leg as ordered. Observe client for signs of pulmonary embolism. Notify physician and pro- vide respiratory support, Administer anticoagulant medications as ordered (specify: e. g., drug, dose, route, and times). Monitor lab values. Inform physician before giving heparin if APPT is outside of range (specify}. Keep antidotes to antico- agulant drugs available: protamine sulfate for heparin, vitamin K for war &in, Closely monitor client for signs of abnormal bleed- ing: bleeding gums, easy bruising, epistaxis, or hematuria. Assess stools for occult blood as indicated. Assessment provides infor- mation about the develop- ment of superficial or deep vein thrombosis. Elevation of legs facilitates venous return. Rest and avoiding massage 1 activi- ties rhat might lead to ~~~0~~s~. Heat catfses vasodilatation and f' circulation to area to resolve thrombus faster. Observation helps identify pulmonary embolism early. Respiratory support may help if the embolus is not occluding the pulmonary artery. Specie action of individ- ual drug. ~ticoa~u Ian~~ prevent further thrombus formation while the body naturally dissolves the clot. Usual range for APPT dur- ing heparin therapy is 1. 5 to 2. 5 times normal. Longer times may indicate risk of hemorrhage. Antidotes reverse the effects of anticoagulant medications and decrease the risk of hemorrhage. Abnormal bleeding may indicate excessive anticoag- ulant therapy. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPARTUM 199 INTERVENTIONS RATIONALES Administer antibiotics as ordered (specify drug, dose, route, times). Measure client's leg and apply antiembolism stock- ings (TED hose) as ordered. Assist client with ambula- tion when ordered. Specify action of drug. Antiembolism stockings promote venous return and 4 venous stasis. Assistance avoids injury and allows early identifica- tion of complications. Explain all interventions Understanding promotes and rationales to client and compliance and decreases family. anxiety. Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (Does client's leg exhibit pain, pallor, redness, or edema? Are bilateral pedal pulses equal? Does client exhibit any signs of respiratory distress? Did client experience abnormal bleeding?) (Revisions to care plan? D/C care plan? Continue care plan?) Management of Therapeutic Regimen, Inefective Related to: Insuficient understanding of condi- tion and therapeutic regimen. Defining Characteristics: Client verbalizes desire to learn about condition and manage own care (specify). Goal: Client will manage therapeutic regimen effectively by (date/time for evaluation). Outcome Criteria Client describes factors contributing to and actions she can take to avoid venous thrombosis. Client relates intent to comply with therapeutic regimen. INTERVENTIONS RATIONALES Assess client's previous knowledge about venous thrombosis. Encourage questions at any time and family par- ticipation in learning. Discuss the impact of venous stasis on thrombus formation. Assist client to identie ways to avoid venous sta- sis: avoid prolonged stand- ing or sitting, change posi- tions at least every 2 hours, avoid crossing legs or using knee gatch on bed. Assist client to identify ways to increase venous return: need to wear sup- port hose correctly, planned rest periods with legs elevated. Teach client about her medications: (specify: e. g., warfarin, heparin, antibi- otics), dose, route, time, drug interactions, need for follow-up lab tests, excre- tion in breast milk, etc. Inform client about risks of bleeding with anticoag- ulants and signs and symp- toms to report immediate- ly. If client is taking warfarin, teach about dietary sources of vitamin K (green, leafy Assessment provides infor- mation about client's knowledge base. Encouragement assures comfort when asking ques- tions. Family support pro- motes compliance. Discussion provides infor- mation about physiologic cause and effect. Assisting client to identify risk factors empowers her to gain control over her risk. Assistance empowers the client and enhances self- esteem. Incorrectly applied hose may cause constric- tion. Anticoagulant drugs may have serious adverse effects if taken improperly. Client should not take other drugs including OTC without checking with caregiver. Early identification of abnormal bleeding allows prompt administration of the antidote. Ingestion of large amounts of vitamin K may 4 the effectiveness of warfarin. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
200 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES vegetables) and possible effects on drug therapy. Ask client to review teach- ing and repeat important concepts. Provide with written information as well as verbal feedback. Praise client for demon- strated learning of new material. Provide with phone number to call for further questions. Interventions reinforce learning of new material. Written information may be reviewed at home. Praise reinforces self- esteem. Provision of phone number ensures access to additional information. Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (Does client describe factors contributing to and actions she can take to avoid venous thrombosis? Does client relate intent to comply with therapeu- tic regimen?) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPARTUM 20 1 Venous Thrombosis Risk Factors + vessel trau thrombophlebitis- 1 venous thrombosis superficial deep saphenous vein femoral vein pelvic veins 1 high risk embolism PUbnar Y | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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Hematomas A hematoma forms when injury to a blood vessel allows bleeding into adjacent tissues. Hematomas sustained as a result of birth trauma are usually small but they may be large enough to result in life-threatening hemorrhage. Puerperal hematomas commonly develop in the vulvar, vulvovaginal, vaginal (at the level of the ischial spines), or retroperitoneal areas. The primary symptom of a hematoma is constant pain that may be severe. Other symptoms include rectal pressure or difficulty voiding. Abdominal pain with increasing girth and unexplained signs of shock may result from a large retroperitoneal hematoma. Risk Factors obstetrical interventions: episiotomy, puden- dal block, forceps delivery genital varicose veins precipitous birth prolonged second stage macrosomic infant primipara PIH, clotting abnormalities Medical Care Administration of blood and clotting factors if Laparotomy with ligation of hypogastric artery or possible hysterectomy for severe hemorrhage indicated Nursing tare Plans Fluid Volume Deficit, Riskfor (159) Related to: Excessive losses secondary to disrupted vasculature. Pain (I66) Related to: Ischemia and edema secondary to blood vessel trauma. Defining Characteristics: Client reports discom- fort (specify location, type, and severity using a pain scale). Client exhibits (specify: e. g., guarding, grimacing, moaning, etc. ). Aclditional Diagnoses and Plans Anxiev Related to: Perceived threat to self or infant sec- ondary to (specify: e. g., postpartum or neonatal complication). Defining Characteristics: Client verbalizes anxiety (specifjr: e. g., feels physically threatened, afraid baby will die, can't sleep, etc. ). Client rates anxiety as a (specify) on a scale of 1 to 5 with 1 being no anxiety and 5 being the most. God: Client will demonstrate decreased anxiety Application of ice packs to perineum after deliv-by (date and time to evaluate). ery and observation Outcome Criteria Client will rate anxiety as a (specify) or less on a scale of 1 to 5 with 1 being least, 5 the most anxi- ety. Client will appear calm (specify not crying, no tremors, HR < 100, etc. ). Incision, evacuation, and ligation of bleeding vessels if indicated Vaginal packing Administration of broad spectrum antibiotics | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
204 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES Assess for physical signs of anxiety: tremors, palpita- tions, tachycardia, dry mouth, nausea, or diaphoresis. Assess for mental and emotional signs of anxiety: nervousness, crying, diffi- culty with concentration or memory, etc. Ask client to rate her feel- ings of anxiety on a scale of 1 to 5. Provide reassurance and support: acknowledge anx- iety, provide time for dis- cussion, and use touch if culturally appropriate. Encourage client to involve significant other(s) in attempts to identify and cope with anxiety. When client is calmer, val- idate concerns with factual information about postpar- tum or newborn condition and what will be done to lessen the risks (specify: bedrest, ice packs, sitz baths, antibiotics, consults, etc. ), Ask client how she usually copes with anxiety and if this would be helpful now. Assist client to plan coping strategies for anxiety. Suggest possibilities: medi- tation, breathing and relax- ation, creative imagery, music, biofeedback, talk-Anxiety may cause the “fight or flight” syrnpathet- ic response. Some-cultures prohibit verbal expression of anxiety. Anxiety may interfere with normal mental and emo- tional funaioning. Rating allows measure- ment of changes in anxiety level. Severe anxiety may inter- fere with the client's ability to t&e in information. Interventions may help 4 anxiety levels. Significant others are also under stress during com- plicated pregnancy. Client may be overly fear- ful. Realistic understand- ing of risks and treatment options empowers the client to participate in her own care. Intervention promotes identification of adaptive coping mechanisms v. mal- adaptive (e. g., smoking, alcohol, etc. ). Developing a plan to address anxiety promotes a sense of control, which enhances coping ability. ing to self, etc. (suggest others). Arrange a tour ofthe NICU if appropriate, or ask for a consult with appropriate caregivers (specify). Provide information about counseling or support individual counseling. groups as appropriate (specify: groups for parents of multiple gestation, con-strategies. genital anomalies, etct). Familiarity and knowledge decrease fear of the unknown. Severe anxiety may require Support groups provide reassurance and coping Evaluation (Date/time of evaluation of goal) (Has god been met? not met? partially met?) (What does the client rate her anxiety as now? Does client appear calm?-specift: not crying, smiling, pulse 72, etc. ) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPARTUM 205 Hematomas Vessel Trauma bleeding into tissues ------A hematoma formation / Vulvar vu1vovaginal 1 visible bluiih-red bulge Vaginal Retroperitoneal 1 pain, pressu 3 Reabsorption application of ice symptomatic katment Rupture resolution Extension Hemorrhage +_I surgical evacuation ligation of bleeding vessel vaginal packing blood transfusion | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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POSTPARTUM 207 Adolescent Mother The adolescent mother may feel overwhelmed by the reality of her infant and the physical discom- forts of the puerperium. In addition, she and her baby may have experienced a complicated preg- nancy or birth. These factors may lead to a pro- longed “Taking-In” phase characterized by with- drawal and preoccupation with physical needs. Teaching methods should take into account the client's age and maturity level. The baby's father should be included when possible. Adolescents may focus on the concrete physical tasks of infant care and neglect sensory stimulation. They may feel shy about asking questions. A supportive atmosphere fosters learning. Contraceptive coun- seling and sex education are important topics, as many adolescent mothers will experience a repeat pregnancy. Social support, financial ability, and educational goals need to be assessed and appro- priate referrals made. In addition to the basic care plans for vaginal or cesarean birth, the following nursing diagnoses may apply to the adolescent mother. Nursing Care Plans Purenting, Altered (193) Related to: Conflict between meeting own needs and those of infant secondary to maternal imma- turity. Defining Characteristics: Specify client behaviors: e. g., inappropriate or non-nurturing behavior towards infant, lack of attachment behaviors (give examples). Client verbalizes dissatisfaction with inhnt or own parenting skills. Coping, Ineffective Individual (2I4) Related to: Inadequate psychological/maturational resources to adapt to adolescent parenting. Defining Characteristics: Specify: e. g., client ver- balizes inability to cope or meet expectations of maternal role (quotes). Client exhibitdreports use of inappropriate coping mechanisms (specify: e. g., substance abuse). and Care Plans Body Image Disturbance Related to: Effects of pregnancy and birth, surgery (specify). Defining Characteristics: Client verbalizes nega- tive response to body after childbirth (specify: e. g., “Look how ugly I am!”). Client exhibits negative nonverbal response to body changes (speci G: gri- macing, crying, etc. ). Goal: Client will demonstrate acceptance of body changes by (datehime to evaluate). Outcome Criteria Client will verbalize acceptance of body changes associated with pregnancy and birth. Client plans health-promoting postpartum diet and exercise program. INTERVENTIONS RATIONALES Establish a trusting rela- tionship with client. Provide for privacy and time for discussion. Sit down. Discussion of body image requires a trusting safe relationship. Sitting down shows the client that the nurse is available and will- ing to talk. Client may need encour- agement to express nega-Encourage client to express her feelings about body | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
208 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES changes, how she views her body now, and fears about the permanency of changes. Assist client to list her con- cerns and provide accurate information about each concern. Reassure client that abdominal muscle tone will return and may be improved with postpartum exercises as approved by her caregiver. Inform client that she may not be able to wear her pre-pregnancy clothes for a while if they have a fitted waist. Suggest clothing with loose or elastic waist- bands (e. g., sweat pants). If client has an abdominal incision, prepare her for its appearance before remov- ing the dressing (specify: e. g., size, location, staples, or stitches). Describe how the incision may look when healed and the importance of incision care to avoid infection and abnormal scarring. Discuss the appearance and cause of stretch marks on hips, abdomen, and breasts. Reassure client that stretch marks will fade with time and may become hardly noticeable. Inform her that creams and lotions will not fade the marks but may tive feelings and fears about her body changes. Expression increases self- awareness. Identification of specific concerns allows develop- ment of a plan to address each concern. The flabby abdominal appearance after childbirth may be the most apparent, unusual, and distressing change for new mothers. Client may assume that she will return to her usual shape as soon as the baby is born. Clothing may be an important indication of social status for client. Preparation helps decrease anxiety when viewing an incision for the first time. Description provides antic- ipatory guidance and rein- forces teaching about care of the incision. Stretch marks are common during pregnancy and may be very distressing to the client. Reassurance and informa- tion help the client cope with permanent changes and incorporate them into her new body image. INTERVENTIONS RATIONALES make her feel more com- fortable. Provide information about weight loss during the puerperium. Assist client to plan an individualized diet and exercise program. Teach client about breast changes during the puer- perium. Reassure her that breast size doesn't indicate ability to nurse her baby. Inform her that breast- feeding will not make her breasts sag but will help her lose weight. Encourage client to discuss concerns about body image and sexuality (e. g., she is unattractive to men now, her vagina is stretched out, and she will be sexually unappealing, etc. ). Correct misconcep- tions. Provide information about self-care related to postpar- tum diaphoresis and lochia flow (e. g., frequent show- ers, pad changes, use of peri bottle, sitz baths). Encourage family and friends to be supportive to client; correct any miscon- ceptions they may express. Provide positive reinforce- ment for indications of positive body image: grooming, posture, etc. Information empowers the client to develop strategies to improve body image afier childbirth. Optimum diet and exercise will assist the client to look and feel her best. Teaching corrects common misconceptions about breast-feeding and its effects on body image. Discussion of concerns allows correction of mis- conceptions that may be fostered by society and some care providers. Promotes positive sexual identity. Information assists the client with personal grooming and care of her body. Social support increases the adolescent client's self- esteem. Positive responses reinforce client's attempts to recon- cile her new body image and make the most of it. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPARTUM 209 INTERVENTIONS RATIONALES Arrange consults as indi- cated (specify: e. g., psychi- atric, dietary etc. ). Anorexia nervosa and bulimia are psychiatric dis- orders related to a distort- ed body image. Support groups provide the client with additional information and self-help Refer client to community agencies as indicated &er discharge (specitjr: e. g., port groups, etc. ). teen parent program, sup-skills. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Does client verbalize acceptance of body changes associated with pregnancy and birth? Does client plan health-promoting postpartum diet and exer- cise program?) (Revisions to care plan? D/C care plan? Continue care plan?) Fumily Processes, Altered Related to: Specify (e. g., role confusion secondary to adolescent parenthood, illness of a family mem- ber, birth of a high-risk newborn, etc. ). Defining Characteristics: Specifjr (e. g., family doesn't communicate openly and effectively among members [Grandmother tells client “You're doing it all wrong, let me do it”]. Family is not adapting effectively with crisis of birth [specify: e. g., family express anger and disapproval towards client or infant. Family or father of the baby refus- es to visit client, won't talk about or hold the baby, etc. ]). Goal: Family will adapt to birth and resume effec- tive functioning by (date/time to evaluate). Outcome Criteria Family verbalizes acceptance of infant and new mother. Family identifies external agencies and support resources. INTERVENTIONS RATIONALES Observe family interac- tions and reactions to the mother and infant. Demonstrate respect and concern for family in a caring and nonjudgmental manner. Provide the family with feedback about perceptions (specify: e. g., “This must be difficult for your family. It's hard to adjust to being a grandmother when you're so young,” etc. ). Encourage verbalization of individual feelings without attacking family members (e. g., guilt, anger, blame, etc. ). Provide accurate informa- tion to family members about client'shnfant's con- dition and prognosis. Encourage family members to identify primary con- cerns. Assist them to note similarities and areas of conflict. Assist the family to list pri- orities, identify choices, and plan ways to adjust to the situation. Observation provides information about family dynamics and reactions to birth. Disrespect or judgmencal behavior will close lines of communication between the family and the nurse. Feedback helps the family to verify or correct percep- tions, and acknowledge feelings and conflicts. Expression of negative feel- ings allows the family to acknowledge the problems they need to work on. Information assists the family to adapt to a chang- ing situation and helps allay unrealistic fears. Encouragement facilitates open communication about concerns. Assisting the family to pri- oritize and problem-solve builds on family strengths. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
210 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES Encourage family to main- tain open communication and support of each other. Provide feedback about observed family strengths. Assist family to identify additional social supports they can call on (specify: e. g., extended family, friends, religious groups). Provide referrals as indicat- ed (specify: support groups, counseling, etc. ). Open communication and support help the family adapt to change. Feedback helps the family evaluate effectiveness of family adaptation during and after discussion. Additional support may be needed to foster family adaptation. Family may not recognize that help is available from sources other than themselves. Referrals provide the fami- ly with additional informa- tion and help. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Does family verbalize acceptance of infant and new mother? Specify using an example. Did fami- ly identify external agencies and support resources to contact? Which ones?) (Revisions to care plan? D/C care plan? Continue care plan?) Health Maintenance, Altered Related to: Substance abuse (specify: tobacco, alcohol, marijuana, etc. ). Poor dietary habits (specify: high fat diet, inadequate nutrients, etc. ). Lack of understanding about (specify: sexuality/reproductive health care needs). Defining Characteristics: Client reports smoking cigarettes (specifjr number of cigarettes or packslday), drinking, or using other drugs (specify type and amount). Client reports poor dietary habits (specify: e. g., f' fat diet, skips meals, drinks soda instead of milk, etc. ). Client states inaccurate information about sexualitylreproductive needs (specify: e. g., “I don't need contraception because I'm never having sex again”). Goal: Client will change behaviors to maintain health by (datehime to evaluate). Outcome Criteria Client will identify unhealthy behaviors. Client will verbalize plan to engage in healthy behaviors (specify: stop smoking, avoid alcohol and other drugs, eat a balanced diet, use contra- ception to avoid repeat pregnancy, etc. ). INTERVENTIONS RATIONALES Assess client's reasons for unhealthy behaviors (may lack knowledge, poverty, addiction, peer pressure, cultural norms, etc. ). Discuss the possible conse- quences associated with the behaviors (specify). Assist client to plan healthy behaviors (specify: quit smoking, change dietary habits, use contra- ception, etc. ). Offer praise and positive reinforcement for plans to change behaviors. Relate healthy behaviors to good parenting of the client's new baby. Assessment provides infor- mation about motivation for unhealthy behaviors. Client will be informed of the risks of unhealthy behaviors. Client will identify the problem and decide on a plan for change. Praise and reinforcement increase client's motivation for change. Maternal health and role modeling affects the child's health and behavior as he grows up. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
~ ~~ POSTPARTUM 21 1 INTERVENTIONS RATIONALES Provide information as needed about healthy behaviors (specify: e. g., nutrition, sexuality teach- ing). Assist client to obtain additional resources if indicated (specify: WIC, AFDC, social services, etc. ). Refer client to supportive services (specify: smoking cessation program, sub- stance abuse programs, peer support groups, resource mothers pro- grams, home tutors, etc. ). The client may lack neces- sary knowledge about nutrition, sexualiy, etc. Poverty may be a factor in poor dietary habits. Lack of transportation may affect ability to obtain health care. Referral provides resources that have been successful in helping clients to over- come addiction and main- tain healthy lifestyles. Peer groups and resource moth- ers programs are especially effective with adolescents. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Does client identi+ unhealthy behaviors? Did client make plans to engage in healthy behaviors? Specify. ) (Revisions to care plan? D/C care plan? Continue care plan?) Growth and Developmmt, Altered Related to: Physical changes of pregnancy and birth. Interruption of the normal psychosocial development of adolescence. Defining Characteristics: Specify client's age and maturity level. Client is underweight/overweight (specify ht, wt, and percentile). Client reports dif- ficulty with peers, or parent(s) related to the preg- nancy and baby. Client verbalizes confusion about plans for the future (specify). Goal: Client will demonstrate adequate growth and age-appropriate psychosocial development while accomplishing the developmental tasks of parenting. Outcome Criteria Client will obtain needed nutrition for recovery, lactation, and normal physical growth. Client will make plans to complete at least a high school edu- cation. Client reports satisfactory relationship with parent(s), significant other, and peers. INTER~TIONS RATIONALES Assess client's physical growth compared to norms for age. Assess maturity of thinking and ability to plan for the future. Tailor discussion to client's developmental level (specify: e. g., concrete thinking, formal opera- tions, etc. ). Reinforce nutrition teach- ing relating it to the client's growth needs as well as recovery and lacta- tion if indicated. Assess the impact of moth- erhood on client's educa- tion and future plans for a vocation or career. Discuss body image issues and correct misconcep- tions (e. g., “I'll never wear a bikini again). Encourage client to finish basic schooling and make realistic plans for the future including childcare. Assessment provides infor- mation about physical growth. Assessment guides plan- ning. Young adolescents may have difficulty relat- ing current behaviors to future consequences. Reinforcement promotes compliance. Young adoles- cents may need more nutrients and calories than adult mothers do. Teen parenting may adversely affect education and skill attainment and the development of a mature identity. The adolescent may fear mutilation or permanent disfigurement from birth. Encouragement assists the client to plan for her future. Inadequate educa- tion and low income | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
212 MATERNAL-INFANT NURSING CARE PLANS INTERYENTIONS RATIONALES become a vicious circle for many teen mothers. Motherhood may affect relationships. Teens need social interaction in order to develop identity and Assist client to assess rela- tionships with parent(s), significant other, and peers (plan ways to improve these if needed). independence. Teach client about the developmental tasks of adolescence (Erikson) and stages of maternal role desires. attainment. Refer client as needed (specify: e. g., special schoolinglvocational pro- grams, etc. ). Teaching may decrease some confusion from con- flicting feelings and Referrals may assist the client to plan a future for herself and the infant. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Does client choose appropriate nutrition? Does client have plans to finish high school? Does client report satisfaction with relationships?) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPARTUM 213 Postpafluin Depression Psychiatric disorders that manifest themselves dur- ing the puerperium are often called “postpartum blues,” “postpartum depression,” or “puerperal psychosis,” although these terms are not recog- nized in the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition revised (DSM- IIIR). Major depression and psychosis during the puerperium are most likely to affect women with a history of psychiatric illness (20%-25% recur- rence rate postpartum). The experience of “post- partum blues,” however, is much more common (50%-80% of all new mothers) and may be relat- ed to hormonal changes and adjustment to new motherhood. Restlessness, agitation, labile mood swings (elation to despondency), abnormal sleep patterns, irra- tionality, hallucinations, and delirium may be used to identify psychosis. The client may have a history of bipolar illness, schizophrenia, or previ- ous puerperal psychosis. The client may experi- ence suicidal ideation, which needs immediate psychiatric intervention. history of psychiatric illness or postpartum depression unwanted pregnancy lack of stable relationships lack of financial and emotional support multiple babies low self-esteem, dissatisfaction with self The client who exhibits signs of depression, and her family, need information and assessment to differentiate the “blues” from major depression. “Blues” Depression Early onset: first few Short-lived: 2-3 days Mild depression Anxiety, irritability, Appropriate fatigue Late onset: 4th week Continue for more Hopelessness, help- ', Agitation Or exagger-days up to 1 year than 2 weeks crying episodes lessness ated slowness of movement Insomnia or excessive sleeping 4 interest 4 energy Unable to concen- trate Appetite changes Feelings of guilt or worthlessness Thoughts of death or Medical Care suicide “Blues”: anticipation, recognition, reassurance Major depression or psychosis: psychotropic medications including antidepressants, antipsy- chotics, lithium, tranquilizers. Psychotherapy, counseling or day-treatment programs. Possible hospitalization and/or electroconvulsive therapy (ECT). Nursing Care Plans Anxiety (203) Related to: Actual or perceived threat to self-con- cept secondary to difficulty adapting to birth and parenting. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
214 MATERNAL-INFANT NURSING CARE PLANS Defining Characteristics: Client reports feelings of (specify: e. g., nervousness, helplessness, and loss of control). Client exhibits (specify: e. g., irritabili- ty, lability, crying, withdrawal, etc. ). Parenting, Risk for Altered (193) Related to: Ineffective adaptation to stressors asso- ciated with parenting a new infant. Defining Characteristics: Client exhibits a lack of or inappropriate parenting behaviors (specify). Client verbalizes (specify: e. g., frustration with baby, self, or ability to care for infant). Family Processes, Altered (209) Related to: Gain of new family member. Defining Characteristics: Family system is not supportive (specify). Family doesn't (specify: e. g., communicate openly, meet the physical or emo- tional needs of its members, etc. ). Additional Diagnoses and Plans Coping Inefective Individual Related to: Inadequate psychological resources to adapt to motherhood; unsatisfactory support sys- tems; altered affect secondary to imbalance of neurotransmitters Defining Characteristics: Client verbalizes that she is unable to cope (specify). Client is unable to care for self or infant (specify: e. g., poor hygiene, doesn't respond to infant's cues, etc. ). Client uses inappropriate coping mechanisms (specify: e. g., denial, substance abuse, etc. ). Client exhibits destructive behavior (specify). Goal: Client will engage in more effective coping behaviors by (date/time to evaluate). Outcome Criteria Client will identify current stresses leading to inef- fective coping. Client will explore personal strengths and plan new ways to cope with stresses. INTERVENTIONS RATIONALES Assess client's affect, per- sonal hygiene, and interac- tion with a support system (e. g., visitors, phone calls). Assess client's attachment behavior towards her infant: eye contact, hold- ing, touch, talking to the baby, etc. Evaluate cultural variation if indicated. Notify caregiver if client avoids looking at or touch- ing infant or makes nega- tive comments about infant. Establish trusting relation- ship with client. Spend time with client, provide for privacy, and remain nonjudgmental. Encourage client to explore how she is feeling using therapeutic commu- nication skills (e. g., use of open-ended questions: “Can you tell me how you're feeling now?” or reflection: “You seem to be sad today”). Assess client for severe depression or thoughts about death or suicide. Notify caregiver immedi-Assessment provides infor- mation about client's abili- ty to cope. Poor attachment behavior may signal a risk for neglect or abuse of the infant. In some cultures the new mother is not expected to provide infant care in the early puerperi- um. Negative comments and avoidance of infant may signal that the infant needs protection. Establishment of trust pro- motes a sense of safety and support for the client. Therapeutic communica- tion assists the client to identify and explore her emotions. Clients who are severely depressed or talking about death/suicide need imme- diate psychiatric help. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPARTUM 215 INTERVENTIONS RATIONALES ately about any indication of suicidal ideation. Evaluate client's ability to relate information in a coherent and generally organized manner. Note any bizarre behav- iors: inappropriate laugh- ter, talking to someone who isn't present, evidence of delusional thinking or hallucinations. Inform caregiver of client's behav- ior. Assist client to identify, and rank in intensity, all current stressors in her life. Observe client's nonverbal behaviors as she describes feelings and stressors. Ask client how she usually copes with similar stressors in her life and if this is an effective method. Explore alternative coping mechanisms with client. Help client identify ways to avoid the stressor, change the situation, or cope with what can't be changed. Help client identify per- sonal strengths that have helped her in the past. Explore how these can help in the present. Provide positive reinforce- ment for description of positive coping mecha- nisms. Evaluation provides infor- mation about organization of client's thought process- es. Bizarre behavior may indi- cate mania or psychosis. Identification and ranking of stressors helps the client organize her thinking. Observation provides addi- tional information about the client and what she is saying. Asking the client to identi- fy and evaluate usual cop- ing mechanisms increases client's self-awareness. Exploration assists the client to identify the potential to alter a stressor and alternatives to usual coping methods. Identification of strengths promotes self-esteem and decreases feelings of help- lessness. Positive reinforcement enhances client's self- esteem and encourages effective coping. INTERVENTIONS RATIONALES Assist client to identify healthy behaviors she can use to reduce unavoidable stresses (e. g., exercise, meditation, relaxation techniques, etc. ). Assist client in formulating a plan to cope more effec- tively with stressors in her life. Encourage client to seek and accept social support during the puerperium. Teach client and signifi- cant other the signs and symptoms of postpartum “baby blues”: transient feelings of sadness, crying, common emotional labili- ty, and feelings of mild depression in the first few days after childbirth. Encourage significant other to be supportive to client during this time and reassure them that this only lasts 2 or 3 days. Provide information about signs and symptoms of developing major depres- sion to report to client's caregiver: severe depression with late onset, lasts more than 2 weeks, and inter- feres with normal activities of daily living. Encourage client and sig- nificant other to plan ways to cope with stress of hav- ing a new baby when they go home. Exercise, meditation, and relaxation techniques help to relieve stress and improve health. Assistance encourages the client to commit to posi- tive changes. Client may have unrealisti- cally high expectations for herself or may need “per- mission” to ask for help. Information provides anticipatory guidance for recognition of emotional fragility that occurs in the first few weeks after birth. Encouragement of support promotes effective family coping. Information allows client and significant other to differentiate between the “blues” and major depres- sion after childbirth. Planning helps family cope with stresses related to car- ing for a newborn. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
216 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES Provide information about community support ser- vices (specify: e. g., support groups, mental health agencies, etc. ). Provide for follow-up phone call or arrange a home visit with client at 2 to 3 weeks postpartum. Information helps client and family to obtain addi- tional help after discharge. Follow-up helps reinforce effective coping and iden- ti+ additional problems that may develop after dis- charge. Evaluation (Dateltime of evaluation of goal) (Has goal been met? not met? partially met?) (Did client identify current stresses leading to ineffective coping? Did client explore personal strengths and plan new ways to cope with stress- es?) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPARTUM 217 Postpartum Depression Postpartum Stresses + Risk Factors + history of bipolar illness schizophrenia previous puerperal psychosis 8ocioeconomic stress Psychosis agitation irrationality labile mood insomnia confusion delusions hallucinations history of major depression previous postpartum depression low self-esteem unwanted pregnancy Major Depression late onset persistent (>2 wk) hopelessness helplessness feelings of failure worthlessness, guilt sleep and appetite changes Suicide Risk Risk to Infant 1 + discomfort fatigue anxiety over parenting skill emotional let-down difficult infant u Postpartum Blues” early onset self-limiting (2-3 days) mild depression anxiety, irritability sudden crying fatigue support Information Reassurance Psychiatric Care | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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POSTPARTUM 219 The birth of a preterm infant, an infant with a congenital anomaly, or a compromised newborn requiring intensive care disrupts the normal par- ent-infant attachment process. In the case of preterm birth, the client may not have completed the developmental tasks of pregnancy. Congenital anomalies may be life-threatening or disfiguring. An otherwise normal term newborn may experi- ence distress during labor and require resuscitation at birth, or the baby's condition may deteriorate in the first few hours of life. All parents must relinquish their “fantasy” baby in order to form an attachment with their real baby. For parents of an at-risk newborn, shock, disbe- lief, grief, guilt, and a sense of failure may compli- cate this process. Nursing Care Plans Fear (I 85) Related to: Life-threatening condition of the new- born (specify). Defining Characteristics: Parents express great apprehension about condition and prognosis of newborn (specify using quotes). Parents exhibit physiologic indications of sympathetic response (specify: e. g., pallor, tremor, etc. ). Family Processes, Altered (209) Related to: Disruption of family routines and expectations secondary to birth of high-risk new- born. Defining Characteristics: Family is not adapting constructively to crisis (specify: e. g., lack of com- munication between family members, lack of emotional support for each other, etc. ). Parent-Infant Attachment, Risk for Altered Related to: Unexpected outcome to pregnancy (specify: preterm birth, infant with congenital anomalies, compromised neonate). Barriers to attachment secondary to intensive care environ- ment. Defining Characteristics: None, since this is a potential diagnosis. Goal: Parents will engage in the attachment process with their infant by (dateltime to evalu- ate). Outcome Criteria Parents will see, touch, and talk to their baby. Parents will verbalize positive feelings towards their baby. INTERVENTIONS RATIONALES Provide parents with infor- mation about their infant at birth (specifjl: e. g., breathing, need for resusci- tation, visible anomalies). Encourage parents to see and touch their baby before transfer to the nurs- ery. If infant is to be trans- ferred to another facility, take parents to the nursery to see the baby or have the baby brought to them in a warmer before transport. Take pictures of the baby and give to parents with a set of footprints. Information helps the par- ents to cope with reality rather than fears of the unknown. Parents pick up on nonverbal cues from staff when there is a prob- lem at birth. Seeing and touching the baby are important to facilitate attachment even if the baby is ill. The parents need to see their baby to begin the attachment process. When the infant is transported, pictures and footprints provide tangible evidence of the baby's existence. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
220 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES Ask transport team to call when they arrive and pro- vide parents with an update on the baby's con- dition. Provide parents with phone number of receiving facility,and encourage calls to check on baby. Assess parents' level of understanding about the baby's problems. Provide accurate informa- tion from a consistent source for parents (e. g., neonatologist, primary NICU nurse, etc. ). Arrange for the parents to visit their baby in the NICU as soon as possible after birth. Provide parents with antic- ipatory guidance before going to the NICU: what they will see and hear in the unit, what they may expect their baby to look like including equipment around him. Use written materials or videos to rein- force teaching. Focus parents' attention on their baby. Point out attractive features or indi- vidual attributes. Address variations from the way a normal term newborn looks (e. g., preterm skin may be red, thin; imma- ture genitalia; baby may be pale, retracting, etc. ). Show pictures of babies Providing information allays fears the parents may have and establishes a rela- tionship with the new facility. Assessment provides infor- mation about parent's learning needs. Accurate information from a trusted source helps the parents resolve their grief and attach to their baby. Early visitation encourages attachment. There may be a “sensitive period” for optimal parental attach- ment. Anticipatory guidance decreases the anxiety encountered in an unfa- miliar environment. The infant may have many monitors attached to him. Pictures in books, or videos help the parents visualize what the NICU is like. Parents may be distracted by the noise and machin- ery of the NICU, increas- ing their feeling of separa- tion from the infant. Drawing their attention to the baby helps them begin the identification process. Parents may be afraid to ask questions about abnor- mal-looking attributes. INTERVENTIONS RATIONALES with corrected anomalies if indicated (e. g., cleft lip). Encourage parents to make eye contact, talk to, and touch their infant. Explain that the infant needs to hear their familiar voices, see them, and feel their touch too. Explain each monitor that is attached to the baby: what it monitors, how it's attached, where the read- out is, and what is a nor- mal range. Explain any alarms that “go off. '' Provide parents with the phone number of the unit, the name of their baby's nurses and instruct them to call or visit when they want to. Assist parents to review their labor, birth, and any resuscitation events. Provide accurate informa- tion and correct miscon- ceptions. Encourage parents to express their feelings about their baby's birth. Reassure them that many parents feel guilty, angry, helpless, or depressed. Provide parents with infor- mation about parent- infant attachment. Note rhe importance even if the baby doesn't survive (if this is indicated). Pictures of corrections are reassuring with disfiguring anomalies. Parents may be afraid they will hurt their baby or interfere with equipment if they touch him. Providing comfort in the form of sound and touch is a par- enting task. Parents may harbor mis- conceptions about equip- ment attached to their baby. They may become upset when the numbers on the read-out change or an alarm sounds. Intervention promotes trust and a sense of securi- ty for parents to know how to get information about their baby. Review helps parents incorporate the events sur- rounding the birth into their present situation. Encouragement promotes expression of normal feel- ings that the parents may think are shameful. Resolution of grief is facili- tated if the parents have been able to form an attachment to their baby. Knowing that they cared for their baby in some way comforts them. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPARTUM 221 ~ ~~ INTERVENTIONS RATIONALES Encourage parents' assis- tance with care-giving activities for their baby: changing diapers, helping with skin care, etc. Acknowledge ambivalent feelings they may have about the baby's nurses. Encourage the mother who planned on breast- feeding her baby to pump her breasts and bring in [he milk for her baby when he is allowed to eat. Praise mother's commit- ment to her baby. Compliment parents on care-giving activities and interest in their baby. Teach parents about their baby's individual responses. Plan neonatal behavioral assessments for a time when parents are visiting and show them appropri- ate ways to stimulate their baby (specify). Promote family support and participation (e. g., grandparents, siblings, etc. ;. Keep a record of parents' or family's visiting patterns and phone calls about their baby. Encourage parents to dis- cuss how they feel towards their baby after several vis- its. Notify caregiver and initi- ate referrals to social ser- vices if family avoids con- tact with their baby. Encouraging parents to assist promotes attachment to the infant. Parents may feel gratehl and jealous of NICU nurses who care for their baby. Breast milk is usually the ideal food for the at-risk newborn. The mother will need to make a major commitment to pump, store, and deliver her milk for the baby. Compliments provide feedback about parenting skills and attachment. Assessments provide par- ents with important infor- mation about their baby's behavior. A preterm or compromised neonate may not respond to parental stimulation as older sib- lings did. Intervention facilitates the whole family's attachment to the baby. A record provides informa- tion about family attach- ment or avoidance of the baby. Encouragement helps par- ents identify beginnings of emotional attachment. Infants who are separated from their parents for a long time after birth are at high risk for neglect or abuse. INTER'WNTIONS RATIONALES Provide support to parents Genetic defects may whose infant has a genetic engender guilt and blame defect. Arrange consulta-in the parents. Genetic tion with a genetic coun-counselors are experienced selor. in helping parents cope and plan for future preg- nancies. Support groups can offer information and ideas to enhance parents adapta-Provide information about additional support systems: e. g., NICU parents groups, parents of children tion. with congenital anomalies, Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Did parents see, touch, and talk to their baby? Have parents verbalized positive feelings towards their baby?) (Revisions to care plan? DIC care plan? Continue care plan?) Grieving, Anticipatory Related to: Potential for neonatal loss secondary to prematurity, compromised neonate or infant with congenital anomalies (specify). Defining Characteristics: Client and significant other report perceived threat of loss (specify quotes: e. g., “Our baby is going to die isn't he? Will our baby ever be normal?”). Goal: Client and significant other will begin the grieving process. Outcome Criteria Client and significant other identify the meaning of the possible loss to them. Client and significant other are able to express their grief in culturally appropriate ways (specify). | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
222 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES Assess the parents beliefs about thc pcrccived loss. Provide accurate informa- tion about the baby's Con- dition and prognosis. Provide information updates from a consistent source. Encourage and assist par- ents to form an attach- ment to their baby. (If the baby is nonviable, allow parents to hold the infant until he or she expires. ) Assisc parents to describe what the perceived loss means to them. Don't minimize the loss (e. g., “Well at least she isn't brain-damaged'). Support the family's cul- tural expressions of loss/grief in a respectful and nonjudgmental man- ner. Teach parents about nor- mal grieving and relate it to their loss of a perfect baby. Describe feelings that they may experience. Provide written materials if literate. Support parents in the stage they are in and assist with redicy-orientation (specifjr: e. g., “I can see that you are angry, this is a normal way to feel,” or “I can see that you are hop- ing things will turn out OK; I am hoping so too”). Assessment provides infor- mation and clarification. Parents may be overly anx- ious due to being unin- formed about current con- dition. Provision of a con- sistent source helps prevent conflicting information. Grief work is facilitated if the parents formed an attachment to the baby and provided some care before death. Identifjring the meaning of this loss helps the parents know what they are griev- ing for and begin the grief process. Different cultures express grief in different ways- the nurse needs to allow and facilitate grief work without being judgmental. Knowing that shock, anger, disbelief, guilt, and depression, etc. are normal reactions will help the par- ents to cope with these feelings. Support assists the parents to identi@ the stage they are in and work through the process without feeling that the nurse is judging them. INTERVENTIONS RATIONALES Encourage parents to ask for support from family and social support system. Social support helps ease the burden of grief and may help with future needs. Religious support may be helpful to parents. Offer to contact the par- ents' clergy or thc hospital chaplain if desired. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (What do client and significant other describe as the meaning of the possible loss? Use quotes. Describe grief reactions the client and significant other express: crying, anger, being stoic, culturally prescribed responses, etc. ) {Revisions to care plan? DIC care plan? Continue care plan?) Breast-Feeding In tempted Related to: Specify (e. g., prematurity, NPO status of high-risk neonate, congenital anomalies: cleft lip/palate, etc. ). Defining Characteristics: Mother desires to breast-feed her infant but is unable to do so because of (specify: e. g., infant is on IV fluids only; preterm infant or infant with congenital anomaly is unable to suc Wswallow effectively, etc. ). Goal: Client will maintain lactation and provide milk for infant until breast-feeding can be resumed. Outcome Criteria Client will identify actions to promote lactation. Client will verbalize understanding of pumping, | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPARTUM 223 INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Discuss client's original intent and desire to pro- vide breast milk for her infant. Assess beliefs, previous experience, knowledge, and role models for breast- feeding. Provide information (writ- ten and verbal) about the benefits of breast milk for her baby. Teach client that breast milk is easily digestible, provides anti- body protection, reduces development of allergies. Provide information (writ- ten and verbal) about pumping the breasts, stor- ing milk (plastic bottles only), and bringing the milk to the hospital for the baby. Provide for privacy and a calm, relaxed atmosphere. Reassure client that lacta- tion is a natural activity in which her body is prepared to engage. Teach client that relaxation is necessary for effective lactation. Describe how the “let-down” reflex is affected by her emotions. Instruct client to get into comfortable positions for pumping. Suggest she keep a glass of water close by. Client may be unaware that she can still provide milk for her baby if nurs- ing is contraindicated. Lack of knowledge or sup- port for breast-feeding may interfere with client's abili- ty to succeed with pump- ing until nursing can be resumed. Teaching provides rein- forcement for providing breast milk for the high- risk neonate. Information helps the client to initiate lactation and store her milk safely Anxiety and embarrass- ment interfere with learn- ing, the “let down” reflex, and milk production. Reassurance helps client to believe in the wisdom of her body. Teaching promotes effec- tive breast milk produc- tion. Maternal tension, emotional upset, or embar- rassment may inhibit the “let-down” reflex. Comfort promotes relax- ation. Pumping (or breast- feeding) stimulates thirst. Describe the feedback loop of milk production and breast stimulation. Teach client to pump at least 8 times in 24 hours. Instruct client to stroke her breast while pumping: the “hind milk” or last milk in the breast contains fat content to promote growth. Instruct client in breast care: wash hands before pumping: wash nipples with warm water and no soap; allow to air dry. Praise client for commit- ment, skill development, and nurturing behaviors. Describe what client will feel when her milk “comes in” (breast engorgement) and what she can do to ease discomfort: suggest warm showers, application of warm, moist cabbage leaves, T frequency of expression of milk, mild analgesics (acetaminophen) as ordered by caregiver. Encourage client to explore her feelings about pumping. Discuss client concerns about working, etc. Praise client's attempts and successes. Reinforce the Understanding the rela- tionship between milk supply and stimulation enhances the client's ability to provide breast milk for her baby. Frequent pumping stimu- lates milk production. Understanding the physi- ology of lactation pro- motes self-confidence. Instruction promotes self- care. Handwashing pre- vents the spread of pathogens; soap may dry the nipples causing cracks. Praise increases self-worth and promotes confidence in abilities. Anticipatory guidance decreases anxiety and pro- motes effective self-care. Moist heat causes vasodi- latation and decreases venous and lymphatic con- gestion. Cabbage leaves are anecdotally reported to be effective in relieving dis- comfort. Emptying the breast J. the sensation of fullness. Client may have concerns that increase anxiety and interfere with successful lactation. Praise helps build self-con- fidence and intent to con- | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
224 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES benefits of breast milk if only for the first few weeks or months. Assist client to obtain a breast pump after dis- charge from the hospital. tinue supplying breast milk. The client may be able to purchase, rent, or borrow a pump from different agen- cies. Refer client as indicated (specify: e. g., to a lactation specialist, CNS, other mothers, or La Leche League, etc. ). information and support A lactation specialist is prepared to assist mothers with special needs. La Leche League provides for breast-feeding mothers. storing, and delivering breast milk for her baby. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Did client identify actions to promote lactation? Does client verbalize understanding of pumping, storing, and delivering breast milk for her baby?) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
POSTPARTUM 225 Parents of the At-Risk Newborn Unexpected Pregnancy Outcome Preterm Birth Congenital Anomalies Compromised Neonate Separation actual environmental Shock and Disbelief Guilt, Sense of Failure Anticipatory Grieving * Interruption of Parent-Infant Attachment Avoidance 4 Neglect Failure to Thrive Abuse Acceptance 1 Resume Attachment | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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227 NEWBORN ~~ UNIT Ill: NEWBORN Healthy Newborn Basic Care Plan: Term Newborn Basic Care Plan: Newborn Home Visit Circumcision Preterm Infant Small for Gestational Age (SGA, IUGR) Large for Gestational Age (LGA, IDM) Postterm Infant Birth Injury Hyperbilirubinemia Neonatal Sepsis HIV Infant of Substance Abusing Mother | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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NEWBORN 229 Healthy Newborn The healthy term infant is prepared for the dra- matic transition to extrauterine life by the events of normal labor and vaginal birth. Contractions result in gradually decreased fetal oxygen and p H and increased carbon dioxide during labor. Descent through the birth canal squeezes the chest, removing some lung fluid. Changes in blood chemistry combine with thermal stimula- tion of birth into a cooler environment, and a suddenly expanded chest to stimulate the first breath. Respiration causes pressure changes in the cardiopulmonary system that result in gradual clo- sure of the foramen ovale, ductus arteriosus and ductus venosus thus initiating adult-type circula- tion. The infant is born awake, alert, and with the necessary reflexes to begin breast-feeding and bonding with his parents. The goals of nursing care for the newborn are to provide warmth and safety, identify any life- threatening problems, and facilitate post-natal adaptation and parent-infant attachment. Warmth and Safety The infant is dried immediately and placed in a warm environment: skin-to-skin with the mother or on a pre-warmed dry blanket under a radiant warmer with controlled temperature Medications: vitamin K 0. 5 to 1 mg, IM to pre- vent hemorrhagic disease of the newborn; eye prophylaxis to prevent ophthalmia neonatorum (1% silver nitrate, 0. 5% erythromycin, or 1% tetracycline ophthalmic preparations) following birth; hepatitis B vaccination and genetic screening before discharge Identification includes matching leg and arm- bands with the mother and possibly footprints and fingerprints before the mother and infant are separated Infant security systems to prevent abduction 4 Bathing is delayed until temperature stabilizes (gloves are worn until the intitial bath is com- pleted) vary by agency 4 Cord care and circumcision care to prevent Use of a car seat for discharge infection or hemorrhage Assessments Immediate assessment of respiratory effort, heart rate, and color followed by appropriate resuscitation measures Apgar scoring at 1 and 5 minutes: heart rate, respiratory effort, color, muscle tone, and reflex irritability; continued at 5 minute intervals until a score of 7 or better is obtained 4 Physical assessment and measurements Gestational age assessment correlated with new- born weight and length Neonatal behavioral assessment Parent-infant attachment assessments Attachment and Bonding Encouragement of breast-feeding and interac- tion during the periods of infant reactivity: first period during the first 30 minutes after birth is followed by sleep; the second period begins around 4 to 6 hours afier birth and lasts 2 to 4 hours Encouragement and support for rooming-in | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
230 MATERNAL-INFANT NURSING CARE PLANS Parent teaching: normal newborn appearance and behavior; infant care and feeding | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
-NEWBORN 23 1 Cardiopulmonary Transition First breath Cord cutting loss of placental vascular bed surfactant -1 surface tension of alveoli opening of + 1 ? PO2-Ductus L PGEz Arteriosus constriction closure vasodilation 86 functional opening of Pulmonary Circulation Y 7 4 loss of umbilical T systemic volume functional closure of Ductus Venosus I -1 pulmonary t systemic vascular vascular resistance resistance ?-pulmonary vascular volume 1 t lymph circulation & pressure t pressure right atrium left atrium 0 absorption of excess lung fluid Foramen Ovale | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
232 MATERNAL-INFANT NURSING CARE PLANS Birth 1. t hour 306 hour 4 hours 8 hours 1" day Discharge Assessment a Pg= TPR (hourly X 4) # cord vessels cord blood to lab (Rh neg. mom) weight, length OFC, chest circ. Bf Px 1 hkel-Stick Hct physical assessment gestational age assessment TPRq Shrif- stable . I maternal HBs Ag weight (MD exam w /in 24 hr) assess voiding aftercirc weight MD exam metabolic screen Meds/Tx neonatal resuscitation vit. K 0. 5mg IM triple dye or alcohol swab to cord skin-teskin or warmer (37%) w probe in place erythromycin 0. 5% ophthalmic, O. U. 4 blood glucose all SGA, LGA, Ik prn hepatitis B vaccine ~ per protocol first bath if temp stable return to warmer until stable then open crib cordcare- circumcision ~ circ care I Nutrition Ellmination breast-feeding 4 suck/ swallow . I stool 4 urine iirst water (bottle baby) first formula breast feeding q 2-4 formula q 3-4 breast q 2-4 assess feeding I Teaching/Other promote attachment ID bands footprints/ thumbprint Infant security instructioxx breast- feeding, burping, holds, bulb syringe, newborn characteristics hepatitis B informatian ongoing teaching at bedside 1 lactation specialist pm photos 4 ID bands 8a remove remove cord clamp provide PKU info appointment for 4 up infant-care information sheets gift pack car seat | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 233 Basic Care Plan: The care plan is based on a review of the prenatal record, labor and delivery summary, gestational age assessment and a thorough physical assess- ment. Specific infant data should be inserted wherever possible. Nursing Care Plan Airway Clearance, Ineflective Related to: Excessive secretions (specify if cause is identified: e. g., secondary to cesarean birth). Defining Characteristics: Infant experiences chok- ing or gagging on excessive secretions; tachypnea; abnormal breath sounds (specify). Goal: Infant will experience a clear airway by (datehime to evaluate). Outcome Criteria Infant's respiratory rate will be between 30-GO bpm. Bilateral breath sounds will be clear to aus- cultation. INTERVENTIONS RATIONALES Suction infant's mouth, Suctioning before birth of then nares with bulb the shoulders clears the syringe after birth of the upper airway before the head. first breath. Neonates are obligate nose-breathers; suctioning the nares may cause gasping and aspira- tion of mouth contents if mouth has not been cleared first. Position infant with head Positioning facilitates slightly down and on a drainage of fluid by gravi- side. Stimulate crying if ty. Crying opens the air- needed. way and improves lymph INTERVENTIONS RATIONALES Assess respiratory rate and effort, note nasal flaring, retractions, or grunting (specify frequency of assessment). Repeat suctioning with bulb syringe or wall suc- tion only as needed to remove excessive secre- tions. Auscultate bilateral breath sounds and apical pulse (specify frequency). When stable, place infant skin-to-skin with mother covered by a warm blanket with bulb syringe readily available. Monitor infant for episodes of increased secre- tions (choking and gag- ging) during periods of reactivity. Clear airway with bulb syringe as need- ed. Teach mother to use bulb syringe: Depress bulb first then insert syringe into side of infant's mouth and release bulb compression. Remove from mouth and depress bulb to discharge contents. Clear mouth before suctioning nose. Notify caregiver if secre- tions continue to be exces- sive. drainage and absorption of excess lung fluid. Assessment provides infor- mation about effectiveness of suctioning and stimula- tion to clear the airway. Tachypnea, flaring, grunt- ing, and retracting are signs of respiratory dis- tress. Excessive suctioning may stimulate a vagal response, causing bradycardia and further compromise. Auscultation provides information about fluid in the lungs and heart rate, rhythm, and regularity. Skin-to-skin promotes warmth and attachment. Bulb syringe allows imme- diate clearance of secre- tions. Infant may experience additional secretions and need for suctioning during the first and second peri- ods of reactivity. Teaching parents promotes timely airway clearance. Depressing bulb first avoids blowing secretions into infant's lungs. Inserting syringe into side of mouth avoids vagal stimulation from touching back of pharynx. Copious secretions are a sign of tracheoesophageal malformations. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
234 MATERNAL-INFANT NURSING CARE PLANS Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (What is respiratory rate? Are breath sounds clear bilaterally?) (Revisions to care plan? D/C care plan? Continue care plan?) Themzorephtion, Ineflecttave Related to: Limited neonatal compensatory meta- bolic temperature regulation. Defining Characteristics: Temperature fluctua- tions in response to environmental factors: e. g., birth into cool environment, wet body, etc. ). Goal: Infant will be maintained in a neutral ther- mal environment by (dateltime to evaluate). Outcome Criteria Infant's axillary temperature will remain between 36. 5 and 37°C (97. 7-98. G"F). INTERVENTIONS RATIONALES Dry newborn thoroughly and quickly and discard the wet blanket. Place infant on a warm blanket under a pre-warmed radi- ant warmer for initial assessment. Assess axillary temperature at birth and when indicat- ed (specify frequency). Wrap infant in warm blan- ket and carry to mother. May place infant skin-to- skin with mother and Drying quickly and plac- ing on a warm, dry surface prevents heat loss by evap- oration. kvillary temperature is preferred to avoid risk of rectal perforation. Assessment provides infor- mation about the neonate's temperature regulation. Kangaroo care provides for warmth and bonding INTERVENTIONS RATIONALES place blanket over mother and baby. Teach &ily about the infant's need for warmth and to keep the infant's head covered. Return infant to warmer as needed. Unwrap infant (except diaper) while under warmer. Position the temperature probe over non-bony area on infant's abdomen and secure with foil patch. Set controls to maintain skin temperature of 36. 5 and 37°C. Check that alarms are turned on. When temperature is 37"C, infant may be quickly bathed while remaining under radiant warmer. Wash and dry the head first, then expose and wash one area of body at a time and dry thoroughly before moving on to another area. Avoid placing infint on cool surfices or using cold instruments in assessment (e. g., scale, stethoscope). When temperature has sta- bilized after bath, dress infant in a shirt, diaper and hat, wrap in 2 blan-Teaching provides infor- mation the family needs to care for their baby. The infant's head provides a large surface area for heat loss. The radiant warmer heats surfaces exposed to it. Covering the infant decreases the amount of warmth reaching his skin. Placing the probe over a bony area will give a false- high skin temp. reading causing the warmer to shut off prematurely. The warmer should be set to a physiologic range and alarms turned on to pre- vent over-heating the infant. Bathing quickly in a warm environment avoids heat loss from evaporation and convection. Placing the infant on a cool surface or using cool instruments increases heat loss by conduction. Interventions promote warmth while assessing the infant's ability to regulate his temperature in an open | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 235 ~~~~ INTERVENTIONS RATIONALES kets and transfer to open crib. Monitor temp per protocol and return to warmer if needed. Place cribs away from win- dows, avoid drafis or air conditioning blowing on the sides of the crib or on the infant. Maintain room tempera- ture at 72°F. Teach family to adjust infant's coverings afcer discharge to the room temperature based on how they are feeling (e. g., if it is very warm, the baby doesn't need to be dressed in sweaters). crib. Heat may be lost directly from the infant's body to cooler air (convection) and to cooler surfaces close to the infant's body by radia- tion. Teaching assists parents to care for their infant. The infant may suffer from hyperthermia if over- dressed. Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (What is infant's temperature? Has it been stable? Specify. ) (Revisions to care plan? D/C care plan? Continue care plan?) Infiction, Risk for Related to: Exposure to pathogens, invasive proce- dures (specify: e. g., cord cutting, injections, heel sticks, circumcision), breaks in skin integrity (specify: e. g., abrasions, spiral electrode site, etc. ), immature immune system. Defining Characteristics: None, since this is a potential diagnosis. Goal: Infant will not experience infection by (datehime to evaluate). Outcome Criteria Infant receives prophylactic eye ointment (speci- fi. ). Sites of invasive procedures or broken skin (speci- fy) show no signs of infection (specify for each: e. g., no redness, edema, purulent discharge, etc. ). INTERVENTIONS RATIONALES Perform a 3-minute hand scrub prior to caring for mothers and infants. Wash hands before and &er touching infant. Wear gloves until after the infant's first bath and when changing wet or soiled diapers. Do not place shared-items in infant's bed (e. g., ther- mometers, stethoscopes, etc. ). Assess maternal records for history of infections and their treatment, HBs Ag, time of membrane rup- ture, maternd fever, appli- cation of internal fetal monitoring, operative delivery. Assess newborn's axillary temperature at birth and report hyperthermia to caregiver. Assess newborn for com- promised skin integrity: punctures from scalp elec- trodes, abrasions, etc. Document findings and include areas in hture assessments for develop-ment of redness, edema, or purulent drainage. A 3-minute scrub removes most pathogens. Washing hands before and after touching infant prevents the transmission of microorganisms between babies. Gloves protect the caregiver from blood- borne pathogens. Sharing equipment may transfer microorganisms from one infant to the next. Assessment of maternal records provides informa- tion about the risk of infection for this neonate. An infant born with a fever may have experienced intrauterine infection. Assessment provides infor- mation about potential sites for invasion by pathogens. Monitoring ensures early identification of infection. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
236 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES Assess cord for number of vessels without touching the cut surface. Provide cord care as ordered (speci- fy: e. g., triple dye, baci- tracin, alcohol, etc). Assess cord for foul odor or puru- lent drainage at each dia- per change. Wipe excess secretions from infant's eyes. Administer eye prophylaxis as ordered (specify: e. g., erythromycin 0. 5% oph- thalmic ointment O. U. ) within 2 hours of birth. Provide mother with infor- mation about hepatitis B vaccination; obtain con- sent. Administer 1st dose of vaccine to infant per protocol (specify drug, dose, and route). Administer injections and perform heel sticks using aseptic technique. Document sites and add to future assessments. Assess circumcision for signs of infection during each diaper change. Rinse penis with water only and place a gauze pad with petroleum jelly over penis (unless a Plastibell has been used) at least 4-5 times per day. Assess inht for signs of infection: temperature instability beyond the first few hours, feeding prob-The cut surfice of the umbilical cord presents a site for proliferation of microorganisms. Neonatal eye prophylaxis is a legal requirement to pre- vent ophthalmia neonato- rum caused by exposure to gonorrhea and/or chlamy- dia in the vagina. Waiting for a few hours promotes attachment during the first period of reactivity. Infants of mothers who are positive for HBs Ag should receive the vaccine at birth. It is recommended for all newborns to prevent hepatitis B infection. Aseptic technique prevents introduction of pathogens during injections and heel sticks. Assessment provides infor- mation about developing infection. Gauze protects the surgical site; petroleum jelly prevents gauze stick- ing to the site. Neonates may exhibit sub- tle signs of infection com- pared to older infants. The infant may merely not INTERVENTIONS RATIONALES lems, lethargy, pallor, apnea, or diarrhea. Notify caregiver. Teach parents to care for circumcision and not to remove yellowish exudate. Teach family to avoid exposing the infant to peo- ple with infections. Instruct family to wash their hands before han- dling the infant. Teach parents to use a thermometer before dis- charge. Instruct them to take the infant's tempera- ture only if he appears ill (hot, lethargic, refusal to eat, diarrhea, dehydrated, etc. ) and to call the doctor for fever > 10 1 “F rectally or 100. 4”F axillary. “look right” or behave c'normally”' Yellowish exudate is granu- lation tissue. Removal may cause hemorrhage and increase the risk of infec- tion. Teaching helps the family to care for their baby and prevent infection. Parents may not know how to use and read a thermometer. Guidelines are provided to ensure prompt treatment if the infant becomes ill. Evaluation (Datehime of evaluation of goal) (Has god been met? not met? partially met?) (Did infant receive eye prophylaxis? Specify time, drug, etc. Provide an assessment of cord, circumci- sion, injection sites, and any areas of broken skin. ) (Revisions to care plan? DIC care plan? Continue care plan?) Nutrition, Altered Less Than Body Requirements Related to: Limited intake during the first few days of life. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 237 Defining Characteristics: Weight loss (specify birth weight compared to current wt. ). Mother's milk has not come in. Insufficient intake of calo- ries (specie caloric needs for individual infant and compare with caloric intake. A term newborn needs 120 calories/kg/day: mature breast milk and regular formula usually contain about 20 calloz). Goal: Infant will establish feeding pattern to obtain needed nutrients by (datehime to evdu- ate). Outcome Criteria Newborn demonstraces effective suck and swallow reflexes. Breast-fed baby nurses well during first 4 hours after birth. Bottle-fed baby retains first water and formula feeding. Infant produces at least six wet diapers per day. Total weight loss is < 10% of birth weight. INTERVENTIONS RATIONALES Weigh infant at birth and each day without diaper or clothing. Cover scale with blanket and zero before weighing. Protect from falls without touching infant. Compare to previ- ous weights. Assess infant's suck reflex during initial assessment. Check swallowing during first feeding. Observe infant for first stool and urine. Monitor all intake and output. Assess airway clearance and bowel sounds during the Monitoring infants weight lossedgains provides infor- mation about nutritional status. Infant needs to be able to suck and swallow effective- ly to obtain nourishment from breast or bottle. Passage of first stool indi- cates a patent anus, first urine indicates renal hnc- tion. Monitoring I&O provides information about nutrition and fluid balance. Infants may have secre- tions during reactive peri-INTERVENTIONS RATIONALES periods of reactivity. Encourage breast-feeding after birth, during second period of reactivity and every 2-3 hours. Assist breast-feeding moth- er as needed. Instruct her to burp infant when changing breasts and when finished and to place infant on right side after eating. Refer to lactation specialist as needed. Inform parents that the infant is getting enough milk if he gains weight and produces six or more wet diapers per day. Provide culturally sensitive care to clients who wish to wait until their milk comes in to breast-feed their babies. Provide water and formula as ordered (specify). Provide sterile water to infants whose mothers choose not to breast-feed within 4 hours. Assess for excessive gagging, choking, or vomiting and notify caregiver. If infant tolerated water feeding, assist mother to provide first formula feed- ing [specify formula and amount) as ordered. ods that should be cleared to prevent aspiration or choking during feeding. Usually bowel sounds are +?' during reactive periods indicating readiness to feed. Assistance helps mother to feed her infint. Burping 4 discomfort and spitting- up. Placing on right side facilitates stomach empty- ing. Lactation specialist can assist The breast-feeding mother who is having dif- ficulty. Parents, especidly breast- feeding, may worry about whether their baby is gct- ting enough to ear. Information provides reas- surance. Some cultures believe char colostrum is not good for the baby. Culturally sensi- tive care promotes mater- nal role-attainment. Sterile water (like colostrum) is nonirritating if aspirated. Assessment provides information about parency of esopha- gus. Formula feeding may begin after assessment of the infant's ability to ingesc water. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
238 MATERNALINFANT NURSING CARE PLANS INTERVENTIONS RATIONALES Monitor infant for signs of feeding intolerance: exces- sive spitting up, abdominal distention, abnormal stools. Notify caregiver. Provide teaching to bottle- feeding family as needed: hold infant close with head higher than stomach (do not prop the bottle); ensure nipple is full of for- mula; burp infant after each ounce or more fre- quently, and when fin- ished; place infant on right side after eating. Teach parents chat a small amount of regurgitated formula is normal after eating but to notify care- giver if infant vomits the whole feeding. Inform bottle-feeding mothers of the schedule suggested by her caregiver (specify) and ensure that sterile formula is available for feedings. Praise parents for success- ful feeding of their new baby. Inform mothers that newborns may be sleepy while they recover from birth buc will wake up and be hungry by the time the milk normally comes in. Teach parents about the normal newborn's stools: meconium, transitional, and milk stools: color, consistency, smell, and fre- quency (specify for bottle- OK breast-fed babies). Feeding intolerance may indicate congenital anom- alies or complications. Teaching promotes parent- infant attachment; pre- vents aspiration; 4 middle ear infections; 4 gas, dis- comfort, and spitting up; facilitates stomach empty- ing. Feeding may need to be repeated if large amount was vomited. Increasing force and frequency of vomiting may indicate pyioric stenosis. Formula takes longer to digest than breast milk so the infant can usually go longer between feedings. Formula should be thrown away after 1 hour to pre- vent contamination. Praise enhances self-esteem and promotes parental role-attainment. Mothers may feel like failures if the inht is sleepy and won't nurse “on time. ” Reassurance promotes con- fidence. Teaching helps parents to identify normal variations in infant stools. INTERVENTIONS RATIONALES Tach parents that weight loss of up to 10% is nor- mal after birth but then their baby should gain about an ounce per day after that for the first 6 months. Provide written and verbal instructions on infant feeding (and formula preparation) at discharge per infant's caregiver. Provide phone number of nursery and information about community resources (specify: e. g., WIC, La Leche League). Teaching provides infor- mation the parents need to assess their infant's growth. Instruction and resources help parents care for their baby after discharge. Evaluation (Dateltime of evaluation of goal) (Has goal been met? not met? partially met?) (Did newborn demonstrate effective suck and swallow reflexes? Did breast baby nurse well dur- ing 1st 4 hours? Did bottle baby retain 1st water and formula? How many wet diapers in last 24 hours? What % of birth-weight has infant lost?) (Revisions to care plan? D/C care plan? Continue care plan?) Injury, Ris& fir Related to: Immaturity and dependency on others for care. Defining Characteristics: None, since this is a potential diagnosis. Goal: Infant will not experience injury by (datehime to evaluate). | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 239 Outcome Criteria Newborn receives vitamin K injection. Mother demonstrates safety when handling, positioning, and caring for infant. Metabolic screening is begun before discharge. INTERVENTIONS RATIONALES Administer vitamin K, per order (specif) time, dose) IM into the middle third of the vastus lateralis. Place matching identifica- tion bands on infant's arm and leg and mother's arm before separating mother and baby. Check numbers before giving infant to mother. Obtain footprints and mother's fingerprint per protocol before separation. Inform parents about hos- pital's infant security sys- tem (specify). Promote attachment and bonding at every opportu- nity. Perform most infant care at bedside and teach parents to provide care. Praise parents' skill and point out infant's individu- ality and response to them. Perform physical assess- ment and gestational age assessment of newborn. Obtain B/P and heel-stick Hct per order (specify). Notify caregiver of abnor- mal findings. Vitamin K is synthesized by intestinal bacteria and used in production of pro- thrombin. Injection is pro- vided to prevent neonatal hemorrhage. The vastus lateralis is a safe site for neonatal injections. Matching identification prevents mix-up of moth- ers and babies. Prints may be used for identification if well done. Also given as souvenirs Infant security system pre- vents abduction. Interventions enhance par- ents' motivation and care- giving skills to promote infant safety. Assessments provide infor- mation about abnormali- ties and risk factors. 4 B/P may indicate hypov- olemia, f' Hct > 65% indicates polycythemia. ~~ ____ INTERVENTIONS RATIONALES Assess blood glucose level per protocol (specify). Initiate feeding per orders (specify) if blood sugar is < 40 mg/d L, and re-check blood glucose level. Monitor infant for devel- opment of jaundice. Notify caregiver. Teach family to pick up and always hold infant by supporting neck and spine. Demonstrate various posi- tions (e. g., football hold, cradling, and upright). Assist family to return- demonstrate. Instruct fam- ily to never shake the baby, Teach family to position infant on right side, sup- ported by a rolled blanket, after feeding. Inform fami- ly that infant should not sleep on his stomach or with a pillow. Show family how to use the bulb syringe to clear excess secretions and stim- ulate the infant to cry should he become pale or apneic. Reassure family that a nurse will respond quickly to their concerns during hospitalization. Teach parents how to bathe their baby, prevent- ing chilling or burning. Instruct them to give sponge baths only until the cord falls off. Hypoglycemia may result in brain damage. Neonatal jaundice indi- cates hyperbilirubinemia that, if severe, may cause kernicterus and brain dam- age. Teaching family to support infant's neck and spine helps prevent injury to the spinal cord. Infants sleeping on their stomach have an increased incidence of SIDS. Placing infant on right side after eating facilitates stomach emptying. Information assists family to clear infant's airway. Teaching helps family pre- vent cold stress or hyper- thermia. Sponge bathing helps keep the cord dry to prevent infection. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
240 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES Teach family to never leave infant alone on an unpro- tected surface. Provide information on normal infant behavior and care. Teach ways to comfort a crying infant: burping, feeding, chang- ing, motion, use of a paci- fier, etc. Obtain specimens for metabolic screening before discharge. Inform parents of the need for repeat test- ing (specify where and when). Provide appointment for newborn check up. Inform parents about the need for immunizations for their baby. Reinforce teaching and provide the nursery phone number and written infor- mation on infant care at discharge. Ensure that infant is properly placed in a car seat at discharge. Teaching prevents falls. Infant may roll or turn over before parents expect. Anticipatory guidance helps parents to provide safe care for their baby. Metabolic screening pro- vides information about conditions that can cause mental retardation or handicaps unless treated. Newborn exams and immunizations help identi- fy abnormalities and pre- vent serious illness. Reinforcement helps par- ents assimilate informa- tion. Phone number pro- vides additional help after discharge. A properly used car seat protects the infant riding in an automobile. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partialy met?) (Date, time, dose, route and site of vitamin K injection? Was metabolic screening begun? Did mother demonstrate safe care and handling of her baby?) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 24 1 Newborn Home Visit The newborn home visit allows assessment of the home environment and family adaptation to hav- ing a new baby. The family benefits from an opportunity to have their questions answered in the comfort of their own home. Anticipatory guidance is provided to promote optimal growth and development of the infant. The care plan is based on a review of prenatal and hospital records and assessments made during the visit. Nursing Care Plans Family Coping: Potentialfor Growth (169) Related to: Effective family adaptation to birth and care of newborn. Defining Characteristics: Family members are able to describe the impact of the new baby. Family members are moving in the direction of providing a healthy and growth-promoting envi- ronment and lifestyle. Health Seeking Behaviors Related to: Limited knowledge and experience caring for a newborn. Defining Characteristics: Infant's mother and family seek information to promote the infant's health (specify: e. g., “When should I feed him cereal? Does he need to eat more?” etc. ). Goal: Family will obtain information about pro- moting infant health by (datehime to evaluate). Outcome Criteria Family participates actively in home visit by ask- ing questions about their baby. Family states intentions to keep all well-baby appointments and obtain immunizations on schedule. INTERVENTIONS RATIONALES Invite family to participate in assessments of their baby. Provide continual information as obtained and praise positive parent- ing evidence. Note general appearance, hygiene, warmth, and color of infant. Evaluate anterior fontanel, infant's head and eye movement. Evaluate baby's response to noise. Auscultate inht's heart rate and rhythm, and breath sounds. Note respi- ratory rate and effort. Inspect umbilicus for red- ness or drainage. Note whether cord has fallen off. Ask family about bathing and skin care practices. Teach not to use powders on baby. Evaluate diaper area for rashes. Suggest frequent diaper changes, exposing the area to air several times a day and use of a barrier ointment (e. g., A&D) for diaper rash. Ask family about infant's elimination patterns: fre-Participation enhances family's knowledge about their baby and promotes feeling comfortable when asking questions. Assessment provides infor- mation about family's need for more information relat- ed to hygiene, appropriate coverings, or neonatal jaundice. Provides information about hydration and neurosensory status. Cardiorespiratory assess- ment provides information about infant's physiologic health. Assessment provides infor- mation about family's understanding of bathing and skin care for their baby. Powders may be aspirated and cause irrita- tion. Diaper rash is a common parental concern. Exposure to air facilitates healing; ointments protect the skin from urine and feces. Information about elimi- nation indicates adequate | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
242 MTERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES quency, color, and consis- tency of stools; # of wet diapers per day. Ask family about infant's sleeping pattern during the day and night. Provide reassurance and suggest sleeping when the baby does for the first few weeks. Weigh the infant and com- pare to birth weight. Ask family about infant feeding behavior: If breast-feeding, is milk in? How often, and for how long does baby nurse? For formula babies, how often and how many ounces does he take? Provide information and support for feeding as needed (specify). Assess attachment and bonding: Does family touch and comfort infant? Do they talk to him mak- ing eye contact? Do they say nice things about the baby? Does baby respond? Assess sibling's response to the new baby. Provide information about safety related to siblings. Assess infant's sleeping area for safety concerns: screens on windows, firm crib mattress without pillows. Crib: not painted with lead-based paint; slats no > 2 318 inches apart; side rails kept up and locked. Provide information as needed. nutrition and function of the gastrointestinal system. Many babies seem to have their days and nights con- fused during the early weeks. Parents often seek information about how to cope with fatigue. Successful feeding with weight gain indicates ade- quate infant nutrition. Mothers may have many questions and concerns about feeding their baby. A lack of bonding behavior may indicate ineffective parenting. Lack of infant attachment behavior may indicate sensory deficits. Focusing on siblings pro- motes self-esteem. Sibling rivalry depends on the older child's age and dependency needs. Assessment provides infor- mation about family's knowledge, or need for information about safety. INTERVENTIONS RATIONALES Encourage family to ask questions. Reinforce need for follow-up immuniza- tions, metabolic screening, and well-baby check-ups. Family should feel com- fortable seeking informa- tion about healthy behav- iors for their baby. Reinforcement of impor- tant preventive-care needs improves compliance. Family may need addition- al assistance to provide optimum care for their new baby. Refer family as indicated (specify: e. g., additional home visit for specific need, social services, WIC, AFDC, support groups, etc. ). Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Did family participate in home visit? Does family state intent to provide preventive health care for their baby?) (Revisions to care plan? D/C care plan? Continue care plan?) Infant Behavior, Organized: Potential fir Enhanced Related to: Normal infant behavior. Defining Characteristics: Infant is able to regulate heart rate and respiration (specify rates). Infant exhibits normal reflexes (specify). Infant's move- ments are smooth without tremors. Infant exhibits appropriate state behaviors (specify: e. g., sleeps soundly, is alert upon waking, follows object with eyes, responds to sound, etc. ). Infant is consoled easily (describe). Goal: Infant will continue appropriate growth and development. Outcome Criteria Parents verbalize understanding of normal infant behavior. Parents verbalize intent to stimulate | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 243 infant development appropriately (specify: e. g., provision of visual, auditory, and tactile sensory input). Parents demonstrate ways to decrease excessive stimulation. ~~ ~~ INTERVENTIONS RATIONALES Discuss infant's needs for sleep and stimulation with parents. Identify different infant states: deep sleep, active EM sleep, drowsy, awake, quiet alert, over- stimulated, and crying. Provide parents with a list of possible infant behav- ioral cues. Assist parents to identifjr their baby's behavioral cues indicating stability and organization (quiet, alert, consolable or self-consol- ing) compared with peri- ods of disorganization and distress (crying, arching, looking away, yawning). Instruct parents to respond appropriately to infant's cues by providing interac- tion and stimulation dur- ing periods of organization and comfort with decreased stimulation when disorganized. Suggest ways to provide visual stimulation: chang- ing mobiles with medium- range, high-contrast colors and geometric shapes or human faces; changing facial expressions and mimic infant's expressions. Suggest ways to provide auditory stimulation: clas-Discussion facilitates par- ents' understanding of their baby's behaviors and needs. A list helps parents identi- fjr infant behaviors they may have overlooked. Assistance enables parents to explore their infant's behaviorat cues and what they mean. Instruction provides infor- mation about ways to enhance infant's develop- ment. The newborn prefers dis- tinct shapes, colors, and the human face. Infant responds by fixed staring, bright, wide eyes to new visual stimuli. Infants respond to sound by becoming alert and ~~~ ~ INTERVENTIONS RATIONALES sical music, vary speech tone and patterns, reciting poetry, using the infant$ name frequently. Suggest ways to provide tactile stimulation: skin-to- skin contact, gentle touch, stroking, infant massage, and toys with varied tex- tures. Suggest rocking, infant swing, placing infant in a front-carrier and going to a walk. Discuss hand-to-mouth behaviors as self-consoling. Provide information about the infant's need for non- nutritive sucking. Help parents ident@ ways to decrease excess stimula- tion: proving a quiet place to sleep, decreasing excess noise, etc. Praise parents for promo- tion of their infant's devel- opment. Provide anticipatory guid- ance about infant growth and developmental changes. Provide referral to parent groups or commu- nity agencies as indicated. Evaluation searching for the source. Touch may help the new- born return to organized state when upset: e. g., swaddling, patting. Movement is often sooth- ing to the infant and pro- vides vestibular stimula- tion. Infants have an innate need to engage in sucking which eating alone may not satisfy. Allowing hand- to-mouth or use of a paci- fier may meet the infant's needs. Infants need periods of calm and decreased stimu- lation in order to reorga- nize behaviors. Praise promotes parental self-esteem and enhances developmentally appropri- ate infant care. Anticipatory guidance and support groups assist par- ents to provide appropriate stimulation to meet their baby's changing develop- mental needs. (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
244 MATERNAL-INFANT NURSING CARE PLANS (Did parents verbalize understanding of normal infant behavior? Did parents verbalize intent to stimulate their baby appropriately? Did parents demonstrate comforting and ways to J( stimula- tion of their infant?) (Revisions to care plan? D/C care plan? Continue care plan?) Nutrition, Altered Rhkfir MOM Than Body Requirements Related to: Parents' lack of knowledge about infant nutrition needs, familial obesity. Defining Characteristics: Parents and/or siblings of infant are obese. Infant is gaining excessive weight for age (specif)). Parent reports feeding infant solid food before 4-5 months of age (speci- Goal: Infant will receive nutrition appropriate for age by (datehime to evaluate). Outcome Criteria Infant will gain appropriate weight for age (speci- e. g., 1 ounce per week). Infant is fed a diet appropriate for age (specify: e. g., breast milk, iron- fortified infant formula). fv>- INTERVENTIONS RATIONALES Assess infant's weight gain compared to expected gain. Assess daily intake. Assess parents' beliefs about infant feeding and weight gain (e. g., does cereal help the baby sleep through the night? A fat baby is a healthy baby?). Provide information about the infant's non-nutritive sucking needs. Assessment provides infor- mation about excessive weight gain and feeding. Parental beliefs may need to be challenged to pro- mote proper infant feed- ing. Parents may be feeding the infant too much just because he appears to enjoy sucking. RATIONALES Provide accurate informa- tion to parents about their baby's daily calorie needs (specify) and how many ounces of formula he needs daily (specify) or approximation with nurs- ing mothers. Provide information about infant's iron needs. Teach parents to use iron-forti- fied formula as instructed by their caregiver. Instruct breast-feeding mothers to continue to take prenatal vitamins and iron and eat a healthy diet while nurs- ing their babies. Explain to parents that solid food remains mostly undigested in the new- born's stomach, providing him with little nourish- ment. Teach parents to delay introduction of solid food until 4-6 months. Assist family to evaluate their eating habits. Reinforce positive eating habits and discuss the con- sequences of obesity. Help family plan a nutri- tious diet based on the food guide pyramid and excluding excess fat and calories. Provide written (or picture) resources. Refa hily members to a dietitian or community resources as indicated (specify: e. g., weight-loss groups). Accurate information helps parents develop an appro- priate feeding plan for their baby. Term newborns have stored enough iron in their liver for approximately 4-6 months. Milk has little iron content. Feeding the infant doesn't result in appreciably longer sleep periods and is not beneficial to the infant. If the family has poor eat- ing habits with obesity, the infant will grow up learn- ing poor habits. Obesity is implicated in heart disease, diabetes, and early death. Parents may be unfamiliar with nutritional needs and meal-planning using the food guide pyramid. Written or picture resources will help in the future. Referral helps the family gain additional informa- tion and support for dietary changes. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 245 Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Is infant's weight gain appropriate? Specify. Is infant being fed an appropriate diet? Specify. ) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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NEWBORN 247 Male circumcision is the surgical removal of the foreskin (prepuce) covering the glans penis. This is usually done for religious, cultural, or social rea- sons. There have been conflicting medical recom- mendations for and against circumcision in recent years. The American Academy of Pediatrics, in 1989, stated “Newborn circumcision has potential medical benefits and advantages as well as disad- vantages and risks. ” Religious circumcision rites are usually performed after the infant is discharged. When circumcision is to be performed in the hospital, the parents need to give informed consent and the procedure is usually done on the day before discharge. The procedure is delayed if the infant is preterm, unstable, or has urethral anomalies or evidence of a bleeding disorder. pain hemorrhage infection damage Medical Care The infant should have received his vitamin K injection at birth; the procedure is done several hours after a feeding to prevent vomiting and aspiration The infant is restrained on a circumcision board with arms and legs secured to prevent move- ment Anesthesia: none, or an anesthetic cream applied topically, or dorsal penile nerve block with 1% lidocaine without epinephrine Circumcision is performed using a clamp (Gomco, Mogen) or Plastlbell; the clamp is removed after circumcision, the rim of the Plastibell remains in place until it falls off after a week Nursing Care Plans Infiction, Risk for (235) Related to: Incision site for microorganism inva- sion and colonization. Additional Diagnoses and Plans Pain Related to: Tissue trauma secondary to surgery. Defining Characteristics: Infant is crying, irrita- ble, and restless with interrupted sleep patterns (describe for individual infant). Goal: Infant will demonstrate decreased pain by (dateltime to evaluate). Outcome Criteria Infant sleeps without disturbance. Infant is not grimacing or crying. INTERVENTIONS RATIONALES Assess infant for signs of pain during and after pro- cedure: grimacing, crying, restlessness and interrup- tion in normal sleep pat- terns. Apply sterile 4x4 gauze pad with petroleum jelly or A&D ointment to cir- cumcised penis (except if Plastibell was used). Cover with a loose diaper. Assessment provides infor- mation about physiologic responses to pain. Sterile lubricated gauze prevents the wound stick- ing to the gauze and pro- tects the wound from pathogens. Loose diapers decrease pressure on the wound. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
248 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES Dress and wrap infant in a blanket and take him to his mother to be fed and comforted immediately after circumcision. Instruct mother to cuddle and talk to her baby while feeding him and to avoid putting pressure on the penis until healed. Position infant on his side after circumcision. Provide access to his hands or a pacifier if mother agrees, for non-nutritive sucking. Observe infant for voiding after circumcision. Note amount and adequacy of stream. Instruct parents to monitor voiding and noti- fv caregiver if infant has problems voiding. Change and teach parents to change diapers frequent- ly after circumcision. Cleanse and teach parents to clean the penis by squeezing water over it and apply the lubricated gauze (except Plastibell circumci- sion) and loose diaper for 2 to 3 days after circumci- sion. Administer mild andgesics if ordered (specify drug, dose, route, times). Teach parents whose infant was circumcised with a Plastibell that the rim should fall off within 8 days and to notify caregiv- er if it doesn't. The infant has not eaten for several hours before cir- cumcision and may have become chilled during the procedure. Instruction helps the mother comfort her baby and avoid discomfort. Side-lying decreases pres- sure on the penis. Sucking provides comfort for the infant. Edema after surgical proce- dure may interfere with infant's ability to void. Teaching prepares parents to care for their baby. Urine is irritating to the open wound. Cleaning removes urine and promotes healing. Water only is squeezed over penis to avoid chemi- cal or mechanical injury. Specify action and side effects of drug if ordered Parents need information to prevent complications after discharge. Evaluation (Dadtime of evaluation of goal) (Has goal been met? not met? partially met?) (Is infant crying? grimacing? Sleeping uninterrupt- ed?) (Revisions to care plan? D/C care plan? Continue care plan?) Fluid Volume Deficit, Risk for Related to: Active losses secondary to surgical complication. Increased vulnerability secondary to immaturity. Defining Characteristics: None, since this is a potential diagnosis. Goal: Infant will exhibit adequate fluid volume by (datehime to evaluate). Outcome Criteria Infant will exhibit no bleeding from circumcision site after procedure. Infant's intake will be similar to output. Infant's mucous membranes will be moist, fontanels flat, and skin turgor elastic. INTERVENTIONS RATIONALES Ensure that vitamin K was given at birth. Assess farni- Iy history for bleeding dis- orders. Notify caregiver before surgical procedures are done. Assess surgical site for bleeding after procedure. Apply gentle pressure to the area with sterile gauze and notify the physician. Teach parents not to wipe off the yellow-white exu- date that forms on the penis after circumcision. Vitamin K is needed for prothrombin synthesis. Infant may have an inher- ited clotting disorder. Pressure is used to obtain hemostasis. The physician may order application of gel foam or need to ligate the blood vessel. The exudate is granulation tissue. Removal may cause bleeding. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 249 INTERVENTIONS RATIONALES Assess infant's heart rate and respiration after proce- dure. Observe and instruct par- ents to check circumcision site for signs of bleeding during each diaper change. Weigh infant daily and compare to previous weight. Monitor all intake and output (specify: e. g., weigh or count diapers), check fontanels and skin turgor q 8 hours. If infant is receiving W fluids, monitor hourly I&O, urine specific gravity and glucose, and lab values for Hgb, Hct, and elec- trolytes as obtained. Maintain a neutral thermal environment. Humidify any oxygen the infant receives. Tachycardia and tachypnea may be signs of excessive fluid loss. Frequent observation pre- vents hemorrhage. Weight loss should not be more than I% to 2% per day. Excess may indicate dehydration Intake and output provides information about fluid balance. Dry mucous membranes and poor skin turgor indicate tissue dehy- dration. IV fluids put the infant at risk for FVD or FVE. Urine sp. gravity > 1. 013 indicates dehydration, gly- cosuria may cause osmotic diuresis, lab values indicate hydration and electrolyte balance. Excessive heat from radiant warmers or phototherapy f fluid losses. Humidified oxygen prevents drying of mucous membranes. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Did infant have any bleeding after circumcision? What is infant's I&O? Describe infant's skin tur- gor, mucous membranes, and fontanels. ) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
250 MATERNAL-INFANT NURSING CARE PLANS Newborn Circumcision As a religious rite: Jewish males are circumcised on their 8th day as a symbol of a biblical covenant. Islamic males are circumcised between 4 and 13 years of age. As a rite of passage to manhood, circumcision is performed at puberty in some cultures. In the United States, circumcision is often done to conform to the cultural norm: because the baby's father or brothers were circumcised Medical opinions and research findings are inconclusive about the health benefits of neonatal circumcision. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN Preterm Infant An infant born before 37 weeks of gestational age is described as preterm. The preterm infant may have difficulty adapting to extrauterine existence because of the premature function of his body sys- tems. The younger the infant, the more problems are likely to arise. Thus, infants born after 30 weeks gestation have a better prognosis than those born earlier. Size is not a good indication of gestation as some infants are small for their gestational age (SGA), or large for gestational age (LGA). The term low birth-weight (LBW) is assigned to an infant weighing less than 2500 g., very low birth-weight (VLBW) for those less than 1500 g. and extremely low birth-weight (ELBW) infants weigh less than 1000 g. Complications Respiratory Distress Syndrome (RDS) Ineffective temperature regulation Persistence of fetal circulation: Patent Ductus Arteriosus (PDA) Intraventricular hemorrhage (IVH) Infection Necrotizing Enterocolitis (NEC) Feeding problems Fluid & Electrolyte imbalances Hyperbilirubinemia Complications related to intensive care replacement; oxygen; artificial or mechanical ventilation Maintenance of a neutral thermal environment Careful management of fluid and electrolytes: insertion of an umbilical artery catheter (UAC) or IV Lab tests, x-rays, CT scans, sensory and devel- opmental testing Medications as indicated: e. g., surfactant, antibiotics, indomethacin for PDA, etc. Nutritional assessment and support: blood glu- cose monitoring, TPN, breast milk, or 24 calo- rie formula via gavage if unable to suck and swallow Treatment of complications as they arise Nursing Care Plans Themoreguhtion, Ineffective (234) Related to: Immaturity and lack of subcutaneous and brown fat. Defining Characteristics: Specify infant's gesta- tional age and birth weight. Specify temperature variations and use of warming devices. Gas Exchange, Impaired (269) Related to: Insufficient surfactant production. Immature neurological development. Defining Characteristics: Specify gestational age, Apgar, blood gases, color, respiratory effort, etc. FLuid Tro Lume Deficit, Risk for (248) Related to: Inadequate intake and excessive losses secondary to preterm birth. Medical Care Respiratory assessment and support; surfactant | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
252 MATERNAL-INFANT NURSING CARE PLANS Infection, Risk for (235) Related to: Sites for invasion of microorganisms. Immature immunological defenses secondary to preterm birth. Paren t-In fan t Attachment, Risk for Altered (219) Related to: Barriers to attachment secondary to neonatal intensive care of preterm infant. Infant Behavior, Disorganized (301) Related to: Immature CNS secondary to preterm birth. Defining Characteristics: Specify for infant (e. g., periods of apnea, bradycardia, muscle twitchingltremors, difficult to console, weak cry, etc. ). Additional Diagnoses and Plans Breathing Pattern, Ineffective Related to: Immature neurological and pulmonary development and fatigue. Defining Characteristics: Preterm birth (specify gestational age), changes in respiratory rate and patterns: tachypnea, apnea, nasal flaring, grunting, retractions (specify for infant). Goal: Infant will experience an effective breathing pattern by (datehime to evaluate). Outcome Criteria Infant's respiratory rate is between 40 and 60 breaths per minute. Infant experiences no apnea. INTERVENTIONS RATIONALES Assess respiratory rate and pattern. Note nasal flaring, Assessment provides infor- mation about neonate's INTERVENTIONS RATIONALES grunting, retractions, cyanosis, and apnea. Provide respiratory assis- tance as needed: suction, oxygen, PPV. Assist with intubation and surfactant administration if needed. Collaborate with the physician and respiratory therapist to maintain effec- tive mechanical ventilation for infant as indicated (specify: e. g., IPPB, inter- mittant positive-pressure breathing). Position infant on side with a rolled blanket behind his back. Administer medications as ordered (specify drug, dose, route, times: e. g., calcium gluconate, amino- phylline, caffeine). Provide tactile stimulation during periods of apnea. ability to initiate and sus- tain an effective breathing pattern. Assistance helps the new- born by clearing the air- way and promoting oxy- genation. The infant may need mechanical assistance with breathing. Surfactant is needed to keep the alveoli open. Collaboration ensures that the infant receives opti- mum care. Mechanical ventilation may be required to maintain respi- ration and oxygenation. Side-lying position facili- tates breathing. Specify action of drugs ordered. Stimulation of the syrnpa- thetic nervous system increases respiration. Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (What is infant's respiratory rate? Is infant experi- encing periods of apnea?) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
~ NEWBORN 253 Nutrition, Altered Less Than Body Requirements Related to: High metabolic rate, inability to ingest adequate nutrients. Defining Characteristics: Preterm (specify gesta- tional age), respiratory distress, unable to suck or swallow (specify: e. g., gags, drools, tires quickly); (specify current caloric intake compared to calcu- lated needs). Goal: Infant will obtain adequate nutrition by (datehime to evaluate). Outcome Criteria Infant receives adequate calories to meet metabolic needs (specify). Infant gains 20-30 g. per day after stabilization. INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Monitor for complications of TPN (frequent blood glucose checks [specify fre- quency]; urine glucose, protein, and specific gravi- ty q 8h). Observe for complications of intralipids (infiltration, f temperature, vomiting, and dyspnea). Assess infant's suck, swal- low, and gag reflexes, and bowel sounds. Weigh infant daily. Maintain strict hourly intake and output. Encourage mothers who want to breast-feed their babies. Provide informa- tion on pumping, freezing, and delivery of milk to the hospital. Decrease metabolic needs of infant: maintain neutral thermal environment, sup- port oxygenation, decrease stimulation. Administer parenteral flu- ids and TI” as ordered (specify). Assess site and rate hourly. Daily weights indicate growth. After stabilization, the infant should gain 20- 30 g/day. Strict intake and output provides informa- tion about FVD or FVE. The mother may need to pump her breasts to ensure milk supply for when the infant is able to breast- feed. Increased metabolism requires f calories and JI those available for growth. Total parenteral nutrition (glucose, protein, elec- trolytes, vitamins and min- erals) may be needed for extremely preterm infants Administer OG feedings if infant has a weak suck, swallow, and gag reflex, as ordered (specify: e. g., breast milk or '/2 strength formula-Pregestimyl). Provide for non-nutritive sucking with a pacifier or hands. Initiate oral feedings as ordered (specify) if infant has a coordinated suck and swallow reflex. May need to use a nipple for preterm babies if bottle feeding. Monitor for respiratory distress and fatigue with feeding. Combine oral and OG feedings as indicated by infant's response. or those who can't tolerate oral feeding. Complications include infiltration, WE, and sep- sis. TPN may result in com- plications such as hyper- glycemia, osmotic diuresis and dehydration. Intralipids (fatty acids) are also needed for nutrition and growth. The infant needs a coordi- nated suck and swallow reflex, and an effective gag reflex in order to begin oral feeding. Bowel sounds indicate peristalsis. Orogastric feeding pro- vides adequate calories. Non-nutritive sucking may gain weight. When the infant is mature enough, oral feedings are begun. A preterm nipple has a larger hole and is eas- ier to suck on. Monitoring provides infor- mation about infant's tol- erance of feeding. Combined OG and oral nippling ensures adequate calories are obtained. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
254 MATERNALINFANT NURSING CARE PLANS INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Advance formula strength as tolerated per orders (specify). Monitor for complications of oral feeding: assess bowel sounds, measure gastric residual, observe for diarrhea, abdominal dis- tention, occult blood in stools. Refer mother to lactation specialist if needed. Praise the quality of the mother's milk and reinforce desir- ability to breast milk for the baby. Advancing the formula slowly ensures tolerance. Monitoring for complica- tions allows early identifi- cation and treatment. The preterm infant is at risk for NEC. Referral assists the mother to initiate and maintain lactation. Providing milk is an important mothering activity and should be praised. Evaluation (Date/time of evaluation of goal) (Has goal been mer? not met? partially met?) (How many calories is infant receiving? What is infant's weight gain (or loss) pattern?) (Revisions to care plan? D/C care plan? Continue care plan?) Injury, Risk for Related to: Immature central nervous system: f ICE hypoxia, f bilirubin, and stress. Defining Characteristics: None, since this is a potential diagnosis. Goal: Infant will not experience CNS injury by (dadtime to evaluate), Outcome Criteria Infant does not exhibit any sign of seizures. Anterior fontanel is flat and soft. Assess infant's prenatal and birth history for signs of fetal distress or perinatal hypoxia. Provide a neutral thermal environment. Maintain adequate oxy- genation. Avoid rapid fluid administration. Suction infant infrequently and only as needed. Position and turn infant with head in alignment with body and slightly ele- vated (1 50-30°). Monitor TPR and B/P per protocol (specify frequen- cy) Assess fontanels and head circumference (specif) fre- quency). Continuously monitor infant for subtle changes in behavior: lethargy, hypoto- nia, f apnea and brady- cardia, signs of seizures. Monitor diagnostic studies as obtained (specify: e. g., ultrasound of head). Monitor labs as obtained: Hct, blood glucose, calci- um, electrolytes, and bilirubin levels. Decrease stimulation by clustering care and han-Hypoxic events f blood flow to the CNS possibly causing rupture of fragile cerebral capillaries and hemorrhage (IVH). Cold stress results in 'I' need for oxygen and a physiologic stress response. Interventions prevent f ICP or rapid changes in fluid volume that may rupture capillaries. Suctioning increases ICl? Elevation of head 4 turning head to side ICP. 4 ICE f Hypotension, apnea and bradycardia, temperature instability are signs of IVH. Signs of IVH include bulging fontanels and increasing head circumfer- ence. Subtle behavioral changes may indicate IVH. Routine ultrasound of the head may be ordered with- in 48 hours to r/o IVH. Alterations in lab values may indicate that the infant is at f risk for CNS damage Preterm infants are at f risk for kernicterus and | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 255 ~~ ~ INTERVENTIONS RATIONALES dling infant as little as pos- sible. Decrease environmental stimuli (specik e. g., noise, lights, movement, and people talking). Teach parents rationale for restricting handling of infant. Promote gentle touch and comfort mea- sures. Teach parents to rec- ognize when infant is over- stimulated. Provide pacifier as indicat- ed for comfort to prevent crying. Provide pain medications as needed for procedures (specify drug, dose, route, and indication). Administer other medica- tions as ordered (specify: e. g., Phenobarbital, indomethacin, vitamin E, etc. ). Monitor infants who have had an IVH for develop- ment of hydrocephalus. risk for kernicterus and brain damage at lower bilirubin levels than term infants. Overstimulation results in a physiologic stress response that f B/P, P, and ICP that may result in IVH. NICU environments may be brightly lit, noisy, and too stressful for the VLBW or ELBW infant. Parents may feel that they are being excluded from caring for their infant. Teaching helps parents make decisions about their infant. Crying f ICP; a pacifier may be comforting for infant who can suck. Pain and crying I' ICP and should be controlled. Specify action of medica- tions ordered (e. g., Phenobarbital to control seizures, indomethacin to close PDA and facilitate oxygenation). Infants who have experi- enced IVH are at f risk for development of hydro- cephalus within a month. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Does infant exhibit signs of seizures? Is anterior fontanel soft and flat?) (Revisions to care plan? D/C care plan? Continue care plan?) Skin Integrity: Impaired, Risk for Related to: Premature skin development: thin, fragile skin, 4 subcutaneous fat; 4 movement; substances applied to skin. Defining Characteristics: None, since this is a potential diagnosis. Goal: Infant will not experience break in skin integrity by (datehime to evaluate). Outcome Criteria Infant's skin is intact without reddened or excori- ated areas. INTERVENTIONS RATIONALES Handle infant gently; do not pull or twist skin. Preterm infant's skin is fragile and susceptible to injury. Assessment provides infor- mation about impaired skin integrity so treatment can begin early. The preterm infant has 4 fat to pad bony areas. Position changes may be stressful to the VLBW or ELBW infant. Assess skin daily for impaired integrity: red- dened areas, dry, cracked areas, or excoriation. Position infant on a pres- sure-reducing mattress (fleece, flotation). Change position as tolerated. Avoid use of tape on infant's skin. If necessary, use protective hydrocolloid barrier under tape. Preterm infant's skin is thin and not securely attached to underlayers. Pulling on tape may tear | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
256 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES INTERVENTIONS MTIONALES Apply barrier to areas of excoriation and monitor healing. Allow barrier to peel off by itself, do not pull. Use hydrogel electrodes. Rotate daily and inspect skin. Provide mouth care and apply lubricant if needed for dry lips. Wash infant only as need- ed with warm water. Use mild soap on diaper area only if needed to remove feces. Apply oil or lubricant as ordered for dry skin after bathing. Cover central line sites with transparent dressing and assess hourly. Change dressing per agency proto- col. Ensure that alarms are turned on for warming devices. Evaluate the need before putting anything on the infant's skin (e. g.. alcohol, tincture of benzoin, provodone iodine, etc. ). the baby's skin. Barriers provide protection to the skin. Barriers protect the skin, promote healing, and allow visualization of the area. Standard electrodes may damage the infant's skin. Rotation and visualization decreases the potential for skin impairment. The infant's mouth may become dry and cracked. The infant doesn't require daily bathing other than eyes, mouth, and diaper area. Soap is irritating and drying to the skin. Preterm infant's skin absorbs more substances than term infant's. Safflower oil may provide the infant with additional fatty acids. Transparent dressings allow hourly assessment to pre- vent infection. Warming devices can burn the infant's delicate skin. The preterm infant's skin may absorb harmful sub- stances or suffer a chemical burn from substances that are not harmful to mature skin. If the substance must Wash off afier application. be used, washing it off 4 the chance of injury. Evaluation (Dadtime of evaluation of goal) (Has goal been met? not met? partially met?) (Is infant's skin intact without reddened or excori- ated areas? Describe. ) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 257 Respiratory Distress Syndrome (RDS) ,------+. 1 surfactant I I' alveoli surface tension. 1 pulmonary circulation 4 4 collapse of alveoli atelectasis pulmonary t P~OPSS~V~ I i I vascular resistance + persistent fetal circulation + ""T need & ability to sustain respiration 1 I peripheral and pulmonary vasoconstriction 402 t COZ levels T 4 anaerobic metabolism + ? lactic acid 1 metdmlic acidosis 1 respiratory aci!osis | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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NEWBORN 259 Small for Gestational Age The infant who is at or below the tenth percentile for weight compared to gestational age is designat- ed as SGA or small for gestational age. Benign fac- tors that can affect size include heredity, sex, and altitude, with high altitudes producing smaller infants. Chromosomal defects (e. g., trisomies) and dwarf syndromes also result in SGA neonates. Intrauterine growth retardation (IUGR) results in an SGA newborn that has not received optimum intrauterine oxygen and nutrients for appropriate growth. IUGR infants who have been chronically deprived, exhibit symmetrical growth retardation. All organs and body systems are proportional but small. Causes include drug and alcohol abuse, maternal smoking, chronic maternal anemia (e. g., sickle cell), vascular disease (heart, renal), multiple gestation, chromosomal anomalies, and congenital infections (TORCH, syphilis). The infant who experiences deprivation later in pregnancy, may reveal asymmetric growth retarda- tion. The newborn exhibits normal head circum- ference and length, but appears wasted with a small chest and abdomen. Hypertensive disorders (PIH), placental infarcts, and advanced diabetes mellitus may result in vascular damage with decreased uteroplacental perfusion. Complications decreased fetal reserves oligohydramnios labor intolerance: fetal distress meconium aspiration cold stress hypoglycemia hypocalcemia polycythemia hyperbilirubinemia Identification of the infant at risk for IUGR: fundal height, serial ultrasound growth mea- surements; ultrasound to rule out congenital anomalies Delivery if close to term or deteriorating condi- tion Suctioning of meconium and neonatal resuscita- tion at birth Thermoregulation, early feeding CBC, TORCH titer, urine CMV and drug screening, chromosome studies, total bilirubin Nurslng Care Plans Thermorephtion, Inefective (234) Related to: Limited metabolic compensatory regu- lation secondary to age and inadequate subcuta- neous fat. Defining Characteristics: Temperature fluctua- tions (specify age/wt, temperature changes and use of warmers). Gas Exchange, Impaired (2G9) Related to: Specify (e. g., decreased reserves, inef- fective respiratory effort, meconium aspiration). Defining Characteristics: Specify (e. g., pale color or central cyanosis, blood gas results, etc. ). | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
260 MATERNALr INFANT NURSING CARE PLANS Parentins Altered (295) Related to: Specify (e. g., separation secondary to infant illness, maternal substance abuse during pregnancy, unwanted pregnancy, etc. ). Defining Characteristics: Specitj. (e. g., infant is in NICU due to meconium aspiration, mother used drugs or alcohol during pregnancy, etc. ). and Care Plans Injury, Risk for Related to: Insufficient glucose for CNS secondary to IUGR and 4 glycogen stores, 4 enzymes needed for gluconeogenesis, and I' metabolism. Defining Characteristics: None, since this is a potential diagnosis. Goal: Infant will not experience injury from hypoglycemia by (datehime to evaluate). Outcome Criteria Infant's blood glucose levels remain above 40 g/d L for the first 24 hours, then above 45 g/d L. Infant does not exhibit signs of CNS injury: tremors, jit- INTERVENTIONS RATIONALES Provide a neutral thermal environment for infant. Assess for and respond quickly to signs of respira- tory distress. Feed infant as soon as pos- sible after birth: breast- feeding or formula fol- lowed by feedings q 2-3 hours. Cold stress causes I' metabolism and further depletion of glucose. Respiratory distress results in I' energy expenditures and depletion of glucose. Early feeding promotes normal blood glucose lev- els after the stress of labor and birth. Frequent feed- ing helps maintain a steady INTERVENTIONS RATIONALES Assess heel stick blood glu- cose level within first hour and per protocol (specify: e. g., q 1-2 hours x 6, then q Gh). Notify caregiver if < 40 mg/d L. Supplement breast-or bot- tle feedings with OG feed- ing as ordered (specify). Administer IV fluids as ordered (specify solution, rate) via pump. Assess IV site, fluid, and rate hourly. Do not increase rate to “catch up” nor stop infusion abruptly. Monitor hourly intake and output. Observe infant for signs of hypoglycemia: tremors, jit- teriness, lethargy, muscle tone, sweating, apnea, seizure activity, LOC. Assess blood glucose level. blood glucose level until the infant is able to replen- ish stores. SGA infants are at high risk for hypoglycemia due to decreased glycogen reserves and increased metabolism. The SGA infant may have a weak suck and need sup- plements in order to main- tain blood glucose and to receive adequate calories: 120-130 cal/kg/day. IV fluids with 10-15Yo glucose solution may be needed. Excessive rate of infusion can lead to hyper- glycemia and cellular dehy- dration. Extravasation of fluids can cause tissue necrosis. Increasing the rate causes hyperglycemia, abrupt dis- continuation causes hypo- glycemia. The infusion needs to be tapered off for infant to adapt. Intake and output and daily weights provide information about ade- quate intake and weight gain or loss. Signs of cerebral hypo- glycemia are similar to signs of other complica- tions. Blood glucose level is tested to verify behav- ioral clues. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 261 INTERVENTIONS RATIONALES __~ ~ INTERVENTIONS RATIONALES Monitor lab results for hypocalcemia or sepsis. Hypocalcemia is frequently associated with hypo- glycemia. The symptoms of hypocalcemia and sepsis are similar to those of hypoglycemia. Explanations and reassur- ance help parents to cope with unexpected and unfa- miliar procedures Explain all procedures and rationales to parents. Provide time for questions and offer reassurance as needed. teriness, lethargy, seizures, and coma. Evaluation (Dadtime of evaluation of goal) (Has goal been met? not met? partially met?) (What is infant's blood glucose level? Describe infant's behavior: Are there any tremors, jitteri- ness, lethargy, signs of seizures or 4 LOC?) (Revisions to care plan? D/C care plan? Continue care plan?) Tissue Perjkion, Altered Related to: Increased viscosity of blood. Defining Characteristics: Infant exhibits (sped@: Hct > 65%, plethora, persistent peripheral cyanosis, 4 peripheral pulses, respiratory distress, jitteriness, hypoglycemia, seizures, hyperbiliru- binemia). Goal: Infant will experience adequate tissue perfu- sion by (datehime to evaluate). Outcome Criteria Infant's Hct will be < G5%. Inhnt will be pink without cyanosis. Monitor infant's Hct levels as obtained. Observe continuously for signs of respiratory distress (tachypnea, flaring, grunt- ing, retractions, and apnea). Provide respiratory support as needed. Assess heart rate, peripher- al pulses, color and color changes q 1 hour. Assess intake and output (specify frequency). Monitor blood glucose lev- els (specify frequency). Observe infant for signs of CNS perfusion: behavior changes, seizure activity. Provide IV fluids as ordered (specify). Assist with exchange trans- fusions as indicated. Monitor bilirubin levels as obtained. Explain all procedures and assessments to parents. Hct levels above 65% indi- cate polycythemia, which causes sluggish blood flow and poor tissue perfusion. Respiratory distress is relat- ed to poor pulmonary tis- sue perfusion with resul- tant f PVR and persistent fetal circulation. Hypoxemia results in tachycardia and possibly heart hilure. Peripheral pulses may be 4, with peripheral cyanosis while the rest of the infant appears ruddy. Poor renal perfusion may result in kidney damage. Hypoglycemia results from 4 stores and f consump- tion of glucose related 10 f' metabolic demands. Observation provides information about signs of 4 central nervous system perfusion. Fluids may be ordered to decrease blood viscosity. Partial plasma exchange transfusion may be indi- cated to lower blood vis- cosity. Excessive RBC's become damaged in the capillaries and break down releasing bilirubin. The infant is at high risk for hyperbiliru- binemia. Explanations help the par- ents to cope with unfamil- iar procedures. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
262 MATERNAL-INFANT NURSING CARE PLANS Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (What is infant's Hct? Describe infant's color. ) (Revisions to care plan? D/C care plan? Continue care plan?) Growth and Development, Altered Related to: Insufficient nutrients and oxygen for optimal intrauterine growth and development; preterm birth. Defining Characteristics: Size/gestational age dis- crepancy (specify: e. g., SGA, IUGR, LGA). Preterm birth (specify gestational age). NICU environment instead of with parents. Goal: Infant will experience improved growth and development by (date/time to evaluate). Outcome Criteria Infant gains 20-3Og. per day after stabilization. Infant is able to maintain a quiet-alert state with varying facial expressions indicating interest. Infant exhibits hand-to-mouth movements and sucking. INTERVENTIONS RATIONALES Assess infant's weight daily. Daily weights provide information about contin- uing patterns of loss or gain. Promote optimum nutri- tion by assisting parents with feedings as needed (specify: e. g., referral to a lactation consultant, offer- ing formula q2h, etc. ). Adequate nutrients are needed for growth. INTERVENTIONS RATIONALES Observe infant's behavioral cues and provide stimula- tion only as tolerated (specify signs of stress for this infant: e. g., tachycar- dia, tachypnea, yawning, withdrawal, crying, etc. ). Promote rest by clustering care, decreasing unneces- sary noise and stimulation, and covering the isolette during sleep. Describe and promote kangaroo care with par- ents. Suggest ways to stimulate the infant (specify: e. g., mobiles, photos, talking to the baby, tapes of music, womb sounds, rocking, stroking, etc. ). Assist parents to provide short periods of infant stimulation and note infant's responses. Observation provides information about the individual infant's need for rest or appropriate stimula- tion. Promoting periods of rest allows the infant to reorga- nize and decrease oxygen and glucose use. Skin-to-skin contact between parent and infant promotes infant develop- ment and parental bond- ing. Provision of infant stimu- lation to promote develop- ment is a parenting role. Parents may benefit from suggestions. Short periods of stimula- tion help the parents assess how their baby is respond- ing without offering too much stimulation at once. Encourage sibling visits with preparation for what they will see and hear in the NICU environment. Provide additional infor- mation about infant devel- opment and referrals to support groups as indicat- ed (specify). Sibling visits promote fam- ily bonding, stimulate the infant, and reassure the siblings that their baby is real. Preparation decreases anxiety. Additional information promotes engagement and effective parenting. Books, videos, and other parents are potential resources. Discuss infant develop- ment with parents and solicit ideas for appropriate stimulation. baby. Parents need information in order to promote opti- mal development of their | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 263- Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (What is infant's weight gain pattern? Describe infant's behaviors and responses to stimulation. ) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
264 MATERNAL-INFANT NURSING CARE, PLANS IUGR Symmetric Asymmetric $ maternal oxygen multiple gestation drug & alcohol abuse TORCH infections PIH placental infarcts severe IDDM I progressive J placental perfusion 1 chronic-l+ 02 J nutrients IUGR Infant $. 7 $02 reserves 1 fetal distress * I polycythemia I I 1 meconium aspiration I I i * hyperbilirubinemia I $. J glycogen reserves . 1 enzymes for gluconeogenesis 1 $ subcutaneous fat &brown fat 4 cold stress 4 + & tissue perfusion ti respiratory distress hypoglycemia | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 265 large for Gestational Age regression syndrome The infant who is at or above the 30th percentile for weight compared to gestational age is designat- ed as LGA or large for gestational age. Benign fac- tors associated with LGA infants include heredity (large parents tend to have large infants) and sex, with males being generally larger than females. Pathologic factors may be erythroblastosis fetalis, transposition of the great vessels, Beckwith- Wiedemann syndrome, and the infant of a diabet- ic mother (IDM). The diabetic mother with poor glycemic control and an uncompromised vascular system delivers large amounts of glucose to her fetus. The fetus responds with increased insulin production by the islet cells in the pancreas. Insulin facilitates uptake of glucose and glycogen synthesis, lipogenesis, and protein synthesis. This results in a macrosomic infant with increased fat stores and organomegaly. Birth deprives the infant of the expected glucose supply placing the neonate at high risk for com- plications of hypoglycemia. Insulin also acts as an antagonist to lecithin synthesis and inhibits pro- duction of phosphatidylglycerol (PG), thereby delaying pulmonary maturation. Complications UDM) CPD, birth trauma: shoulder dystocia, cephal- oxytocin use, forceps or cesarean delivery RDS, slow respiratory development * hypoglycemia, hypocalcemia 0 polycythemia, hyperbilirubinemia cardiomegaly, congenital heart defects, caudal hematoma, fractures, Erb's palsy, facial paralysis Medical Care Prevention through maternal glycemic control Estimation of fetal size and pelvic adequacy- Frequent blood glucose testing after birth IV therapy with 10%-15% glucose until stable Assessment for injury: x-ray, CT scan during pregnancy possible planned cesarean birth Nursing Care Plans Gas Exchange, Impaired (263) Related to: Immature respiratory development and insufficient surfactant production secondary to maternal diabetes mellitus. Defining Characteristics: Specify (e. g., signs of respiratory distress at birth, central cyanosis, blood gases, or oximetry readings). Tissue Pe@sion, Altered (261) Related to: Obstruction secondary to blood vis- cosity/polycythemia. Defining Characteristics: Specify (e. g., color, res- piratory effort, hematocrit, etc. ). Growth and Development, Altered (262) Related to: Excessive glucose use secondary to maternal diabetes mellitus. Defining Characteristics: Specify infant's age, weight, and percentile. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
266 MATERNAL-INFANT NURSING CARE PLANS Additional Diagnoses and Plans Injury, Risk for Related to: Birth trauma secondary to large size; insufficient glucose secondary to transient hyper- insulinism. Defining Characteristics: None, since this is a potential diagnosis. Goal: Infant will not experience injury from macrosornia or hypoglycemia by (dadtime to evaluare). Outcome Criteria Infant does not exhibit signs of birth trauma: frac- tures, cephalhematoma, Erb's palsy, or facial paral- ysis. Infant's blood glucose levels remain above 40 g/d L in the first 24 hours. INTERVENTIONS RATIONALES Review labor progress and birth records for indica- tions of prolonged labor or difficult delivery (e. g., for- ceps, shoulder dystocia, etc. ). Provide warmth and assess for cardiorespiratory stabil- ity at birth. Assess for signs of congeni- tal anomalies: heart defects, caudal regression syndrome. Assess infant for bruising, decreased movement of arms or facial asymmetry. Palpate clavicles for frac- tures: note crepitus. Assess head for molding and Review provides informa- tion about potential injuries and guides a thor- ough assessment. Cold stress and respiratory distress deplete the infant's blood glucose supply. Infants of diabetic mothers are at increased risk for congenital defects: trans- position of the great arter- ies, VSD, PDA, femoral hypoplasia, and caudal regression syndrome. Macrosomia or forceps intervention may result in bruising or injury. Nerve injury to the brachial plexus or facial nerve results in decreased move- ment. INTERVFNTIONS RATIONALES injury. Differentiate between caput succeda- neum and cephalhe- matoma by noting posi- tion of swelling relative to cranial sutures. Report findings of injury to caregiver. Arrange hr- ther testing as ordered (specify: e. g., x-ray, CT scan, etc. ). Discuss birth injuries and treatment plan with par- ents. Allow time for ques- tions and refer to caregiver as needed. Feed stable infant within the first hour after birth: breast-feeding or formula followed by feedings q 2-3 hours. Assess heel-stick blood glu- cose level within first hour and per protocol (specify: e. g., q 1-2 hours x 6, then q Gh). Notify caregiver if < 40 mg Id L. Monitor lab results for glu- cose, calcium, hematocrit, and bilirubin levels. Administer IV fluids via pump as ordered (specify solution, rate). Assess IV site and rate hourly. Monitor hourly intake and output. Titrate feedings and IVF as ordered to maintain ade- quate blood glucose levels. Additional testing may be indicated to confirm clini- cal findings. Parents may become angry about birth injuries. Discussion and referral helps increase understand- ing. The infant with hyperin- sulinism will quickly deplete his blood glucose after birth. Frequent blood glucose assessments provide infor- mation about effectiveness of feedings or IVF in maintaining blood glucose. The infant of a diabetic mother is also at risk for hypocalcemia, poly- cythemia, and hyperbiliru- binemia. IV glucose may be indicat- ed to maintain blood sug- ars. Frequent assessment prevents complications of IV therapy. Hourly I&O provides information about fluid balance. The infant will gradually decrease insulin produc- tion as glucose supply is | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 267- INTERVENTIONS RATIONALES Observe infant for signs of hypoglycemia: tremors, jit- teriness, lethargy, C mus- cle tone, sweating, apnea, seizure activity, 0 LOC. Assess blood glucose level. Explain condition to par- ents. Reassure them that the infant's insulin produc- tion will probably adapt within a few days. Refer parents to additional resources as indicated (specify: e. g., infants with congenital heart defects may be referred to American Heart Association for more information). Evaluation decreased. Titration ensures adequate blood sugar levels during this transition. Observation provides early recognition of complica- tions. Parents may have high anxiety if their infant requires IV fluids. Referrals provide addition- al resources to parents with special needs. (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (Does infant have any birth injuries? What is infant's blood glucose level?) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
268 WTERNAGINFANT NURSING CARE PLANS Infant of Diabetic Mother ? maternal blood glucose ? fetal blood glucose 1 t fetal insulin production ? uptake of amino acids t glucose uptake into 3-lipolysis I muscle and fat I 1 1 1 T protein synthesis t glycogen synthesis t lipid synthesis 1 fetal macrosomia | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 269 Postterm Infant The infant born after 42 weeks of gestation is defined as postterm. Primiparity, grand multipari- ty, and history of prolonged pregnancy are factors associated with postterm gestation. In some preg- nancies thought to be postterm, an error has been made in calculating gestational age due to varia- tions in menstrual cycles and ovulation. Rare fetal conditions associated with prolonged pregnancy are anencephaly and fetal adrenal hypoplasia. Complications of postmaturity are thought to be associated with oligohydramnios and placental degeneration. The fetus receives inadequate nour- ishment and oxygen and suffers distress related to cord compression. Meconium is passed and remains thick because of decreased amniotic fluid. The postmature infant has a characteristic appear- ance. The infant is alert with eyes wide open. The body appears long and thin with almost no subcu- taneous fat. The infant's skin is meconium stained, loose, dry, and cracked, without vernix or lanugo. Fingernails are long and may also be stained. Comnlications meconium aspiration syndrome perinatal hypoxia cold stress hypoglycemia polycythemia hyperbilirubinemia neonatal seizures Medical Care Ultrasound for gestational age and fetal anom- * NST, CST, delivery before 43 weeks Suctioning on the perineum with visualization alies and suction of rneconium below the vocal cords before initiation of respiration Respiratory support, blood gas analysis, x-ray Labs: blood glucose, Hct, bilirubin Nurslng Care Plans Themoreguhtion, Ingective (234) Related to: Immature regulatory mechanisms. Insufficient subcutaneous fat and brown fat sec- ondary to postmaturity. Defining Characteristics: Specify infant's gesta- tional age. Describe temperature fluctuations and warming devices used. Injwy, Risk for (260) Related to: Insufficient glucose levels for metabo- lism secondary to postmaturity. Purent-Infant Attuchrnent, Risk for Altered Related to: Abnormal infant appearance sec- ondary to postterm birth. Separation of infant and parents secondary to need for intensive care. (219) Eldditlonal Diannoses and Plans- Gas Exchange, Impaired Related to: Meconium obstruction of airway. Pulmonary immaturity resulting in deficient sur- factant production. Persistence of fetal circulation. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
270 MATERNAL-INFANT NURSING CARE PLANS Defining Characteristics: Progressive signs of res-INTERVENTIONS RATIONALES piratory distress (specify: nasal flaring, grunting, ~~ retractions, tachypnea, tachycardia, pallor, cyanosis). Acidosis (specify ABG's). (Specify x-ray results: e. g., “ground glass appearance”). Specify thick rneconium visualized below the vocal cords. Goal: Infant will experience adequate gas exchange by (dateltime to evaluate). Outcome Criteria Infant will have a Pa O, > 50-80 torr, Pa CO, of 45-55 torr, p H 7. 25-7. 45, Sa O, > 94%. INTERVENTIONS RATIONALES Assist caregiver to suction the infant's mouth and nose when head is born but before trunk delivers. At birth, gently place infant under a radiant warmer. Dry quickly, remove wet blankets, and place on a dry, warm blan- ket. Suction or assist with suc- tioning the neonate at risk for meconium aspiration before stimulating respira- tion. When airway is clear, stim- ulate respiration and resus- citate per Neonatal Resuscitation Protocol. Assess respiratory rate. Observe for signs of dis- tress: flaring, grunting, retracting, tachypnea, apnea. Assess infant's color and muscle tone. Auscultate apical heart rate and breath sounds, assess BIP (specify frequency). Provide oxygen as needed (Specify: blow-by, oxy- hood, PPV with ambu bag and mask or endotracheal tube). Suctioning the oropharynx clears meconium before Assist with exogenous sur- the chest is expanded at factant administration as birth. indicated (Specify preven- tive or rescue). Interventions prevent cold stress, which also depletes oxygen reserves. Clearing the ainvay before initiation of breathing pre- vents meconium aspira- tion. The Neonatal Resuscitation Protocol pro- vides for optimal oxygena- tion of a distressed neonate. Tachypnea (rate over 60) indicates respiratory dis- tress. Observations pro- mote early recognition and treatment for the compro- mised neonate. Assessment provides infor- mation about the infant's Assist with initiation of mechanical ventilation as indicated (specifjr: e. g., CPAP, IMV, IPPB with PEEP, HFV, ECMO). Monitor blood gas status as obtained (specify: e. g., Tc O,, Tc PO,, Sa O,, and ABG's). Monitor ventilator settings and Fi O,. Assist with assessments and weaning infant from ventilator when stable. tissue oxygenation and energy reserves. Tachycardia may indicate distress, bradycardia may indicate severe distress. Rales may indicate meco- nium aspiration. Blood pressure needs to be main-tained for adequate pul- monary perfusion. Oxygen needs to be pro- vided based on infant's condition and respiratory ability. Exogenous surfactant may be administered to infants with RDS or meconium aspiration to replace defi- cient surfactant and decrease surface tension of alveoli. (Specify rationale for type of mechanical ventilation prescribed. ) Mechanical ventilation and high oxygen levels are asso- ciated with air leaks, pneu- mothorax, retinopathy, and bronchopulmonary dysplasia. The goal is to decrease settings and wean the infant as soon as toler- ated. Monitoring blood gases provides information about infant's response to oxygen administration and ventilation. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 27 1 INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Administer IV fluids via infusion pump as ordered (specify fluid, site, rate). Assess IV hourly. Monitor hourly intake and output. Administer medications (e. g., antibiotics, amino- phylline, calcium glu- conate, Priscoline, dopamine) as ordered; (speci Fy: drug dose, route, times). Monitor infant for thera- peutic and adverse effects of medications. Assist Respiratory Therapist with chest phys- iotherapy as ordered (spec- ify). Monitor x-ray results as obtained. Provide nutrition by TPN or OG until infant is sta- ble and able to suck. Suction infant only as nec- essary. Pre-oxygenate and post-oxygenate infant when suctioning. Provide stimulation if infant becomes apneic. IV fluids are initiated to maintain circulating vol-activity and stimulates res- piration. ume and replenish glucose. Hourly assessments pre- vent fluid overload or injury from infiltration. Explain all equipment and procedures to infant's par- ents. miliar procedures and Information reduces par- ent's anxiety about unfa- equipment. Monitoring I&O provides information about fluid balance. Urine output should be 1-3 cc/kg/hr. (Specify action of pre- scribed drugs in facilitating gas exchange. ) (Specify therapeutic effects expected related to gas exchange. Provide rationale for adverse effects. ) Chest PT may be ordered to facilitate removal of meconium and thick secre- tions from the lungs. Serial x-rays may indicate worsening or improvement of condition. TPN or OG feedings pro- vide glucose and nutrients without excess energy expenditure for the neonate with respiratory distress. Pre-and post-oxygenation replaces gases lost during suctioning. Stimulation increases Sym- pathetic nervous system Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (What are infant's blood gases? Is the Pa O, > 50- 80 torr? Pa CO, between 45-55 torr ? p H 7. 25- 7. 45? Sa O, > 94%?) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
272 MATERNALINFANT NURSING CARE PLANS Meconium Aspiration Syndrome intrauterine hypoxia 1 meconium passage into amniotic fluid 1 aspiration of rneconium I + + + chemical airway & production of 5-02,r CO2 pneumonia pneumothorax (R to L shunt) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN Infants at high risk for birth injury include breech presentations, macrosomic infants, those experi- encing a prolonged second stage of labor or opera- tive obstetrics (forceps, vacuum extraction, and cesarean delivery). Injuries may be minor such as bruises, petechiae, abrasions, subconjunctival hemorrhages, or small lacerations. Cephalhematoma, fractures, and peripheral nerve damage are more serious injuries that usually resolve without further complication. Life-threat- ening injuries include abdominal or spinal cord injury, subdural or intracranial hemorrhage, and perinatal asphyxia with hypoxic-ischemic encephalopathy (HIE). Hypoxic-ischemic injury may result in seizure disorder, cerebral palsy, or mental retardation. The goals of nursing care are to identify the infant at risk and promote safe birth practices. All infants should be assessed for potential injury soon after birth. Prompt identification promotes early treat- ment and may prevent further complications. Medical Care. Neonatal resuscitation Diagnostic studies: x-ray, ultrasound, CT scan, EEG Laboratory: Hgb, Hct, blood glucose, bilirubin, electrolytes, spinal fluid Prevention or treatment of metabolic and respi- ratory acidosis Fluid and electrolyte administration Medication to control seizures Surgical repair Nursing Care Plans Gas Exckange, Impaired (269) Related to: Insufficient oxygen supply secondary to intrauterine hypoxia, difficult delivery, birth trauma. Defining Characteristics: Progressive signs of res- piratory distress (specify: nasal flaring, grunting, retractions, tachypnea, tachycardia, pallor, cyanosis). Acidosis (specify ABG's). Infection, Risk for (235) Related to: Impaired defenses secondary to birth trauma. Additional Diannoses and Plans Injury, Risk for Related to: Tissue trauma secondary to difficult or precipitous birth process (specify e. g. malpresenta- tion: breech, face; nuchal cord; shoulder dystocia; forceps/vacuum assisted birth; prolonged second stage, unattended precipitous birth, etc. ). Defining Characteristics: None, since this is a potential diagnosis. Goal: Infant will not experience further injury by (datehime to evaluate). Outcome Criteria Identified birth injuries are resolved without com- plication. ~-~ ~ ~ INTERVENTIONS RATIONALES Review labor and delivery summary. birth record guides focused Review of the labor and assessment for potential birth trauma. Examining the infant under a radiant warmer Examine the infant under a warmer with an adequate light source. allows complete visualiza- | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
274 h4ATERNAL-INFANT NURSING CARE PLANS ~~ INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Observe infant's resting posture for flexion, sym- metry, and spontaneous movement. Assess skin for erythema, ecchymosis, petechiae, abrasions, or lacerations. Assess head for shape, position, and neck ROM. Palpate for appropriate molding, caput succeda- neum, cephalhematoma, or signs of skull fracture. Palpate fontanels. Observe face for symmetry of muscle tone. Assess blink, pupil, and suck reflexes. Assess eyes for subconjunc- tival hemorrhage. tion without causing cold stress. A good light source is needed to examine skin discoloration. Before disturbing the infant, observation pro- vides information about possible fractures or neuro- logical damage. Infant should have all 4 extremi- ties flexed (except frank breech infants whose legs may be extended due to uterine positioning). Skin assessment provides information about soft tis- sue trauma incurred dur- ing birth. Facial petechiae may result from a tight nuchal cord, shoulder dys- tocia, or facial presenta- tion. Forceps injuries are usually the shape of the forceps. Holding the head at an angle implies neck injury, inability to move through ROM indicates neurologi- cal damage. Caput is edema of the presenting part that usually crosses sutures. Cephalhematoma is bleeding into the perios- teum and usually does not cross sutures. Fractures may be palpated as depres- sions. Abnormal reflexes indicate cranial nerve injury. Subconjunctival hemor- rhages are usually benign, Assess nares for patency. resulting from pressures on the head during birth. Deviated septum may result from compression during birth. Infants are obligate nasal breathers. Assess extremities for sym-Asymmetry of movement metry of movement and or tone in extremities may intact long bones. Palpate indicate nerve injury or clavicles noting any bumps fractures. Palpation of the or crepitus. clavicles provides informa- tion about fractures, which are common with large infants. Evaluate equality of palmer and plantar grasp. Assess abdomen for size, shape, and distention or discoloration. Auscultate bowel sounds. Evaluate infant reflexes: Moro, Babinski, and trunk incurvation. Document and report abnormal findings from physical exam to infant's caregiver. Assist with diagnostic studies as ordered (e. g., x- ray, CT scan). Explain injury to parents. Provide reassurance that the condition should resolve spontaneously (if appropriate). Inequality of plantar or palmer grasps may indicate neurological injury. Abdominal trauma may result in internal bleeding and shock. Abnormal or lack of reflex response to appropriate stimulation may indicate neurological injury. Accurate documentation facilitates evaluation of subsequent changes in condition. Infant's caregiv- er should verify abnormal findings. Diagnostic studies provide information about the sus- pected injury. Explanation and reassur- ance promote parent understanding and bond- ing with their baby. Frequently the injury will resolve spontaneously without disfigurement. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 275 INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Monitor identified injuries Continued assessment pro- every shift for resolution vides information about and healing or develop-resolution or need for ment of complications. additional interventions. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Describe injuries identified. Is there evidence of resolution without complications? Describe. ) (Revisions to care plan? D/C care plan? Continue care plan?) Physical Mobility, Impaired Related to: Neuromuscular injury; musculoskele- tal injury secondary to difficult birth. Defining Characteristics: Inability to move body part, J, ROM, 4 muscle strength (specifjr for infant: e. g., signs of Erb's palsy, facial paralysis, fractures, neck or spinal cord injuries, etc. ). Goal: Infant will regain physical mobility by (datehime to evaluate). Outcome Criteria Infant is able to move affected body part normally. Infant doesn't experience complications from impaired mobility (specify: e. g., aspiration, dis- placed fracture, contractures, etc. ). INTERVENTIONS RATIONALES Review labor and delivery Review of birth events and summary and physical and assessment findings pro- neurological assessment vides information about findings. identified injuries affecting physical mobility. Assessment provides infor- mation about the degree of Assess for spontaneous movement of affected area, muscle tone, preferred position, range of motion or indications of pain, (specify frequency). Maintain anatomical align- ment with use of blanket rolls. Position infant on unaffected side. Dress and handle infant carefully to avoid putting additional strain on affect- ed area. Immobilize fractures as indicated (specifjl: e. g., with a fractured clavicle, the long sleeve of the infant's shirt may be pinned across chest to immobilize the arm on the affected side). Teach family to care for the infant without putting stress on the injured arm or shoulder. Evaluate the infant with facial paralysis for ability to suck and swallow. Assist with feeding by use of a soft nipple and holding the infant's mouth as needed. Provide artificial tears or lubrication for the affected eye if it remains open. Perform passive range of motion exercises q 2-4 hours on the affected side for infants with Erb's palsy as ordered. Maintain splinting of arm affected with Erb's paraly-immobility and signs of improvement. Anatomical alignment pre- vents abnormal stress on joints and tissues when the infant is unable to move area spontaneously. Careful handling prevents further injury and compli- cations. Immobilization promotes comfort and healing of fractures. Teaching empowers family to care for their infant safely. Evaluation and assistance prevents aspiration and promotes adequate nutri- tion. Lubrication prevents drying of the eye in facial paralysis. Passive ROM exercises help to prevent contrac- tures, physical deformities, and promotes joint func- tion during periods of paralysis. Splinting may be indicated to maintain correct place- ment of the humerus. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
276 MATERNAL-INFANT NURSING CARE PLANS INTERVENTION§ RATIONALES sis as ordered. Assess for circulation and skin integrity q 2 hours. Teach family to perform ROM exercises or main- tain splinting as indicated. Encourage family to hold and stimulate infant. Provide information about the injury, expected dura- tion of symptoms, and referrals as indicated for Assessments provide infor- mation to prevent compli- cations from splint (obstructed circulation, skin break down). Teaching family correct techniques for ROM and splint care ensures that infant will receive needed interventions afier dis- charge. Family may be afraid of hurting the infant. Encouragement assists the family to handle the infant safely while meeting emo- tional and developmental needs. Information helps the fam- ily to cope with the new- born's injury. Referrals pro- vide continuing care after discharge. Evaluation (Datdtime of evaluation of goal) (Has goal been met? not met? partially met?) (Is infant able to move affected body part normal- ly? Has infant experienced any complications from impaired mobility? [Specify potential complica- tions for particular injury. ]) (Revisions to care plan? D/C care plan? Continue care plan?) Tissue Perfusion, Altered (Cerebral) Related to: Decreased cerebral blood flow and oxygenation secondary to perinatal asphyxia (hypoxia and ischemia). Increased ICP secondary to birth trauma or intracranial bleeding. Defining Characteristics: Specify for infant (e. g., Apgar scores c 7; inadequate resuscitation efforts; acidosis [specify cord blood gases or ABG]. Decreased muscle tone; LOC [lethargy, coma]; seizures; abnormal posturing. Signs of ICP: apnea, bradycardia, bulging fontanel, wide cranial sutures, etc. ). Goal: Infant will experience adequate cerebral tis- sue perfusion by (date/time to evaluate). Outcome Criteria Infant is well-oxygenated (specify: e. g., Sa O, > 94%) with arterial p H 7. 25-7. 45. B/P appropriate for age and weight (specify range). Anterior fontanel is soft and flat. Identify the at-risk fetus and prepare for birth with adequate personnel and functioning equipment for neonatal resuscitation (speci G: e. g., call NICU stag pediatrician, etc. ). Assess respiratory effort, heart rate, and color at birth. Provide vigorous resuscitation to distressed newborn per Neonatal Resuscitation protocol. Document immediate assessments (including Apgar and cord blood gases), interventions and infant response. Provide warm humidified supplemental oxygen ther- apy as ordered (specify: e. g., oxyhood, ventilator: type, Fi02, rate, etc. ). Identification of the at-risk fetus and preparation for birth promotes effective resuscitation of the dis- tressed neonate. Timely and correct neona- tal resuscitation promotes cerebral oxygenation and prevents or corrects acido- sis. Documentation assists in identifying infants who experienced intrauterine hypoxia, provides informa- tion about appropriate resuscitation efforts and infant's response. Interventions promote cerebral oxygenation. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 277 INTERVENTIONS RATIONALES INTERm ONS RATIONALES Monitor Sa O,, Tc O,, and ABG's as obtained. Suction only as needed providing oxygen before and afier intervention. Position infant with head midline and HOB elevat- ed. Decrease environmen- tal stimulation. Promote rest by clustering care. Assess anterior fontanel (specify frequency). Observe infant for behav- ioral changes, decreasing LOC, or shrill cry. Maintain a neutral thermal environment and normo- glycemia by early feedings or IV fluids (or TPN) as ordered (specify). Monitor blood glucose levels per protocol (specify). Assess BIP, apical and peripheral pulses, skin color, and capillary refill (specify frequency). Monitor Hct as obtained. Assess hourly intake and output. Observe infant for signs of seizure activity (e. g., rhyth- mic jittery movements that persist when the extremity is flexed or are accompa- nied by rhythmic eye movements). Monitoring oxygen levels provides information about effectiveness of res- piratory interventions and guides treatment. Suaioning may J, oxygen levels and 9 ICl? Assist with diagnostic test- ing: blood glucose, calci- um, and electrolyte levels; spinal tap; EEG, CT scan. Interventions promote 4 ICP Assessments provide infor- mation about 'I' ICP and CNS irritation or depres- sion. Thermal and glucose regu- lation promote optimum cerebral oxygenation. Assessments provide infor- mation about tissue perfi- sion. Intake and output provides information about infant's fluid balance and tissue perfision. Observation provides early identification of subtle signs of cerebral injury. Administer medications as ordered (specify drug, dose, route, time: e. g., Phenobarbital). Provide support and infor- mation for the infant's family. Encourage family participation in care of infant. Provide referrals as indicat- ed after discharge (specify: e. g., pediatric neurologist, social services, programs for children with special needs, early intervention programs, etc. ). Diagnostic testing helps rule out hypoglycemia, hypocalcemia, or altered electrolyte balance as a cause for jitteriness. CSF is obtained for signs of bleeding or infection. CT scan may identify brain injury. EEG may identify seizure activity. (Specitjr action of drugs ordered: e. g., anticonvul- sant, antibiotic. ) Support, information, and encouragement assist the family to cope with their infant's condition and pos- sible poor prognosis. Providing care by the fami- ly enhances bonding and attachment. Referral is indicated for the family of an infant likely to experience long-term disability (e. g., cerebral palsy, mental retardation, etc. ). Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (What is Sa O, ? Is arterial p H 7. 25-7. 45?) (Is B/P within specified range? Is anterior fontanel soft and flat?) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
278 MATERNAL-INFANT NURSING CARE PLANS abdominal trauma I bruising hemorrhage lupture: liver spleen kidneys bowel Prolonged 2nd stage 7 CPD Breech Delivery I cervical or spinal cord injury perinatal hy-poxia shoulder cephalic I dystocia (forceps) I seizures I I------ 11 hy-poxic-isc hemic encephalopathy clavicle conjunctival fracture hemorrhage peripheral hemorrhage nerve facial nerve damage paralysis retinal Erb's palsy 7 forceps marks bruises petechiae abrasions lacerations v cephalhematoma cerebral palsy mental retardation intracranial hemorrhage subgaleal hemorrhage cranial fracture | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 370 Hyperbilirubinemia is defined as a serum bilirubin level greater than 12 mg/d L for a term neonate or more than 15 mg/d L for a preterm infint. Asian and Native American infants normally have higher bilirubin levels than Caucasian or African- American babies (up to 2 times as high). Bilirubin is a by-product of red blood cell break- down. It is normally conjugated in the liver and excreted through the feces and urine, giving them their characteristic color. When blood levels rise above approximately 5 mg/d L, bilirubin moves out of the blood causing jaundice (icterus), a yel- low discoloration of the skin or sclera. Higher lev- els may result in bilirubin deposits in the brain, a condition known as kernicterus. Neurological consequences of kernicterus may include: seizures, ADHD, cerebral palsy, and mental retardation. Kernicterus may result from bilirubin levels > 20 mg/d L in a term infant or as low as 12 mg/d L in a compromised preterm baby. Jaundice is defined as either pathologic or physiologic. Pathologic Jaundice Cause: excessive RBC destruction due to Rh or ABO incompatibility (hemolytic disease) infec- tion, polycythemia, cephalhematoma, acidosis, and hypoglycemia Jaundice occurs within the first 24 hours of life Bilirubin rises more than 5 mg/d L/day Bilirubin levels exceed 12 mg/d L Physiologic Jaundice Cause: normal RBC breakdown, liver immatu- rity, and lack of intestinal bacteria 50% of term and 80% of preterm neonates Jaundice begins after 24 hours (term) or 48 Disappears by 7-10 days Bilirubin does not rise more than 5 mg/d L per hours (preterm) day Bilirubin levels do not exceed 13 mg/d L Breast-feeding and/or breast milk jaundice begins 3-5 days after birth and may persist up to 6 weeks Bilirubin & Jaundice Cephalocaudal progression of jaundice may be used to roughly estimate the level of bilirubinema. 0. 2-1. 4 mg/d L-normal level, no jaundice 3 mg/d L-jaundice of nose only 5 mg/d L-jaundice of whole face 7 mg/d L-jaundice over chest 10 mg/d L-jaundice over abdomen 12 mg/d L-jaundice of legs 20 mg/d L-jaundice of soles/palms Medical Care Early feeding, frequent breast-feeding Lab work: Hgb, Hct, serum bilirubin, total pro- tein, direct and indirect Coombs, reticulocyte counts Transcutaneous bilirubin meter Phototherapy Exchange transfusion | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
280 MATERNAL-INFANT NURSING CARE PLANS Nursing Care Plans Breast-Feeding, Interrupted (222) Related to: Excessive bilirubin levels secondary to breast milk jaundice. Defining Characteristics: Physiologic jaundice beginning at 4-5 days (specify infant's age and bilirubin level). Bilirubin level exceeds 15 mg/d L, mother is instructed to interrupt breast-feeding for 24 hours, pump breasts, and resume nursing as desired when bilirubin levels fall. Additional Diagnoses and Plans Injury, Risk for Related to: Increased blood levels of unconjugated bilirubin; effects of phototherapy; effects of exchange transfusion. Defining Characteristics: None, since this is a potential diagnosis. Goal: Infant will not experience injury by (date/time to evaluate). Outcome Criteria Infant's bilirubin levels are less than (specify for individual infant). Infant does not exhibit signs of neurological injury: irritability, lethargy, rigidity, opisthotonos, or seizures. Infant's temperature remains between 36. 5-37°C (97. 7-98. 6"F), heart rate between 1 10-160, respirations between INTERVENTIONS RATIONALES Review prenatal and labor and delivery summary for infant risk factors for hyperbilirubinemia leg., hemolytic disease, preterm, ABO incompatibility, infection, hypoglycemia, infection, cephalhe- etc. ). matoma, excessive bruising Review provides informa- tion about infants at high risk for pathologic hyper- bilirubinemia (e. g., Rh or or petechiae etc. ). INTERVENTIONS RATIONALES Assess infant for jaundice by pressing skin over a bony area and releasing. Assess in natural light moving from head to soles of feet, including mucous membranes and sclera (specify frequency: e. g., q shift). Assess transcuta- neous bilirubin levels as indicated. Notify caregiver if jaundice is noted within the first 24 hours, or if jaundice extends to the infant's legs, increases by more than 5 mg/d L in one day, or reaches 12 mg/d L. Monitor serum bilirubin levels as obtained (specify frequency). If infant is receiving phototherapy, protect blood specimen from light. Monitor other lab work as obtained (e. g., Hgb, Hct, platelets, total protein, serum glucose, etc. ). Observe infant for subtle signs of neurological injury: changes in behav- ior, lethargy, irritability, rigidity, opisthotonos, or seizure activity. Notify caregiver. Explain the etiology and significance of hyperbiliru- binemia to family. Teach them about the process and goals of therapy (spec- ify: e. g., phototherapy, exchange transfusion). Jaundice progresses in a cephalocaudal direction. Artificial light may mask the beginning of jaundice. Transcutaneous monitor- ing is a noninvasive method of determining bilirubin levels. Pathologic jaundice that may lead to kernicterus begins within the first 24 hours with bilirubin levels rising to z 13 mg/d L and increasing 2 Smg/d L/day. Phototherapy light will degrade sample. Monitoring provides infor- mation about factors con- tributing to the hyper- bilirubinemia. Changes may be subtle. There is no specific blood level that signals beginning risk for kernicterus. Preterm or compromised neonates may be affected at lower levels than healthy term infants. Explanations assist the family to understand the therapy. Ultraviolet light changes unconjugated bilirubin into a water-solu- ble form (lurnirubin) for easier excretion. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 28 1 INTERVENTIONS RATIONALES Administer prescribed phototherapy If infant is to be under bili lights, cover infant's closed eyes with appropriate shield applied to prevent slip- ping. Place shield over testes per protocol. Place nude infant on diaper under light source (specify type and safety precau- tions: e. g., distance of light) and turn every 1-2 hours. Monitor infant's tempera- ture and temperature of isolette (specify frequency). Provide phototherapy with a fiberoptic bilirubin blan- ket if available. Provide meticulous skin care to perianal area after each stool. Assess skin q 2 hours. Do not use oil- based products on infant's skin during therapy. Remove infant from lights for feedings and parent- infant interaction. Remove patches and assess eyes for injury or drainage. For infant who is to receive exchange transfu- sion, ensure NPO status (specify time frame: e. g., 2 Eye shields protect the reti- na from injury from ultra- violet light. Covering testes may protect them from injury. Turning the nude infant frequently allows greater skin exposure to the light. Exposing the infant may result in hypothermia. Heat from phototherapy lights may cause hyper- thermia. Bilirubin blankets promote warmth and provide a light source without the need for eye shields. Parents may interact more with their baby, Frequent loose greenish bowel movements are a common effect of pho- totherapy. Skin care pre- vents injury. Oil-based products may cause burns. Isolation during pho- totherapy may interfere with parent-infant bond- ing. Frequent eye assess- ments help detect injury from light or incorrect eye shield application. Infants experiencing pathologic hyperbiliru- binemia from hemolytic disease may require INTERWNTIONS RATIONALES -4 hours). Check resusci- tation equipment and place at bedside. Place infant under a radiant warmer with temperature probe in place for proce- dure. Check blood per agency policy (specify). Warm blood as indicated. Monitor vital signs and observe for signs of trans- fusion reaction before, during, and after exchange transfusion. Assist caregiver as needed. Document amounts of blood removed and infused and infant's toler- ance of procedure. Observe cord for signs of bleeding after procedure and monitor infant for therapeutic or adverse effects. exchange transfusion. NPO status and emer- gency equipment at bed- side ensure rapid resuscita- tion if a sensitivity reaction occurs. The infant is under a radiant heat source to prevent complications from cold stress. Interventions ensure that the correct blood is given to the infant. The blood should be warmed in a blood warmer to protect the RBC's. Close monitor- ing identifies early signs of transfusion reactions or infant intolerance. Assistance may be needed to perform transfusion smoothly. Documentation details the amounts given and withdrawn and infant's response. Observation provides information about hemo- stasis, improvement of condition, or complica- tions. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (What is infant's bilirubin level? Does infant exhibit signs of neurological injury: irritability, lethargy, rigidity, opisthotonos, or seizures? What | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
282 MTERNAL-INFANT NURSING CARE PLANS is infant's temperature? What are the infant's heart rate and respirations?) (Revisions to care plan? D/C care plan? Continue care plan?) Fluid Volume Deficit, Risk for Related to: Increased losses from evaporation, and frequent loose bowel movements. Decreased intake secondary to the effects of phototherapy. Defining Characteristics: None, since this is a potential diagnosis. Goal: Infant will maintain adequate fluid balance during phototherapy (specify datehime to evalu- ate). Outcome Criteria Infant will have at least 6 wet diapers/day. Infant's skin turgor will be elastic, anterior fontanel soft and flat, and mucous membranes moist. INTERVENTIONS RATIONALES Monitor daily weight. Assess infant's hourly intake and output (weigh diapers, 1 gm = 1 cc). Monitor number, color, and consistency of bowel movements. Assess urine specific gravi- ty (specify frequency). Monitoring weight pro- vides information about excessive fluid losses. Assessment of intake and output provides informa- tion about fluid balance. Infant should have output of 1-2 cclkglhour. Phototherapy may result in fluid loss from frequent loose stools. Monitoring provides information about losses. Specific gravity provides information about fluid balance. High sp. gravity INTERVENTIONS RATIONALES Assess skin turgor, mucous membranes, and anterior fontanel q 2 hours. Notify caregiver of signs of dehydration. Provide additional fluids during phototherapy (spec- ify: e. g., 25% more formu- la with more frequent feedings; breast-feed q 2-3 hours; additional water as ordered). Show parents how to assess skin turgor, mucous mem- branes, and fontanel for signs of dehydration. Teach them that the infant should have 6 to 8 wet diapers daily. Initiate and maintain IV fluids as ordered (specify: fluid, rate, site). Assess N site hourly for rate, color, temperature, and edema. Monitor lab values as obtained (specify :e. g., Hct, electrolytes etc. ). (> 1. 030) indicates dehy- dration, low (> 1. OIO) indicates fluid overload. Assessment provides infor- mation about dehydration of tissues: skin turgor, dry mucous membranes, and sunken anterior fontanel. Caregiver may initiate IV fluids if p. 0. intake is insufficient to meet fluid needs. Additional fluids are neces- sary to balance the losses from therapy. Phototherapy may result in increased fluid losses through the skin, urine, and loose bowel move- ments. Explanations and teaching assist parents to care for their infant after discharge and seek medical treat- ment for dehydration. IV fluids may be required to maintain fluid balance or venous access if infant is to have an exchange trans- fusion. Assessment provides infor- mation about complica- tions of IV therapy: infil- tration, infection, or incor- rect rate. Lab values indicate fluid and electrolyte balance or imbalance. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
~~ NEWBORN 283 Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (How many wet diapers has infant had? Describe skin turgor, mucous membranes, and anterior fontanel. ) (Revisions to care plan? D/C care plan? Continue care plan?) Farnib Process, Altered Related to: Disruption of family bonding and attachment with infant due to treatment restric- tions. Defining Characteristics: Family system cannot interact effectively with infant during photothera- py (specify: e. g., infant under bili-lights except for feeding, mother discharged before infant, etc. ). (Specify others: e. g., mother doesn't come to visit infant, parents don't talk to each other, moth- er is crying, etc. ). Goal: Family will adapt to disruption caused by treatments by (datehime to evaluate). Outcome Criteria The family will verbalize feelings associated with disruption of interaction. Family will maintain a functional process of support for one another. INTERVE”I1ONS RATIONALES Assess family members' interaction with each other and infant. Encourage family to talk about their experience regarding infant's treat- ments. Elicit feelings (e. g., fear, guilt, or isolation). Discuss financial concerns as needed. Assessment provides infor- mation about family processes. Encouragement helps the family to identify and ver- balize feelings and con- cerns. The family may be worried about ability to pay for extra hospital days. INTERNENTIONS RATIONALES Acknowledge family's feel- ings and concerns. Assist family to resolve feelings and fears with accurate information. Teach family about the usually benign nature of infant's condition as indi- cated. Explain pathophysi- ology and treatment ratio- nales on a level they can understand. Remove infant from under lights and remove eye shields when family visits. Encourage attachment and bonding activities. Praise parents for interaction and note infant's responses to them. Promote family cohesive- ness by encouraging dis- cussion and problem solv- ing with input from all members. Help family to identify options and make choices as needed (specify: e. g., who cares for the home and other children, is home therapy an option, etc. ). Refer family as indicated (specify: e. g., social services for financial problems; counseling for dysfunc- tional communication pat- terns, etc. ). Acknowledgement indi- cates respect and validation for family's experience. Providing accurate infor- mation decreases fear of the unknown. Teaching reinforces fami- ly's understanding of the condition and treatment. Allays anxiety. Interventions promote family-infant attachment and bonding. Eye contact is important for both baby and parents. Praise rein- forces positive behaviors. Encouraging the family to work with each other to solve problems promotes effective family processes. Assistance helps the family move from feelings to planning solutions to their identified problems. Referral may be indicated for financial concerns or severely disrupted family processes. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
284 MATERNAL-INFANT NURSING CARE PLANS Evaluation (Datehime of evaluation of god) (Has goal been met? not met? partially met?) (Specify feelings family verbalized. Describe how family supports one another and decisions they have made to maintain functionality as a family. ) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
~ NEWBORN 285 Hyper biliru binemia Rh or ABO incompatibility (other causes)-b f hemolysis of fetal RBC's * f erythropoesis Erythroblastosis Fetalis anemia hypxia heart failure 1 Hydrops Fetalis 1 anasarca pulmonary effision 1 severe respiratory distress cardiac failure + + globin 1 unconjugated released into bilirubin + iron-blood stream for reuse bound to protein I hyperbilimbinemia jaundice kernicterus 1 bilirubin encephalopathy Liver (+ glucuronyl transferase) I I * conjugated bilirubin 4 bile 4 intestine (+ intestinal bacteria) $. seizures mental retardation cerebral palsy 4 4 stercobilin urobiligen reabsorption feces urine $. excretion | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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NEWBORN 287 Neonatal Sepsis The newborn is at increased risk for serious infec- tion because of decreased immunity, ineffective leukocytes, and a poorly defined inflammatory response. Maternal immunoglobulin G (Ig G) crosses the placenta mainly during the last few weeks of pregnancy and provides protection against some bacteria. Preterm infants do not receive this benefit. Breast-feeding provides immunoglobulin A (Ig A) and other substances that protect the newborn from infection. Causes Prenatal exposure may be transplacental (rubel- la, CMV, HIV, syphilis, etc. ) or from ascending chorioamnionitis caused by bacteria associated with preterm SROM. During labor and birth, the infant may be exposed to pathogens such as group B 13- hemolytic streptococcus, gonorrhea, her- pesvirus, chlamydia, hepatitis B, and HIV from the mother's reproductive tract. lococci or enterococci. External exposure at birth may include staphy- Nosocomial infections most frequently include staphylococcus, enterococci, Klebsiella, or Pseudomonas. Signs tk Symptoms vague, nonspecific changes; infant doesn't look right hypothermia, temperature instability poor feeding, abdominal distension hypoglycemia hypotonia, S activity poor perfusion: pallor, mottling, cyanosis signs of respiratory distress (G-strep) seizure activity Medlcal Care Cultures and sensitivity: blood x 2, CSF, urine CBC with diff, CW, blood glucose, ABG's, Antibiotics x 2 started before culture results; electrolytes, chest x-ray continue for 1 to 3 weeks if cultures are positive (appropriate drugs), 3 to 5 days if no growth Supportive care: IVF, oxygen, ventilation Observe for complications: DIC, meningitis Nurslng DPagnoses Tbmoregzllatioi,e&tive (234) Related to: Nonspecific effects of infection on neonate. Defining Characteristics: Specify fluctuations of temperature and use of warming devices. Fluid lrolume D@cit, Risk for (282) Related to: Decreased intake secondary to poor feeding. Parent-Infant Attachment, Risk for Altered (219) Related to: Separation of mother and infant sec- ondary to need for neonatal intensive care. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
288 MATERNAL-INFANT NURSING CARE PLANS Additional Dlaunoses and Care Plans mfection, Risk fir Related to: Spread of pathogens secondary to identified sepsis and an immature immune system (specify others: e. g., portal of entry: UAC). Defining Characteristics: None, since this is a potential diagnosis. Goal: Infant will not experience spread of infec- tion by (datehime to evaluate). Outcome Criteria Infant's heart rate remains c 160 (specify range for infant). Respiratory rate c 60 (specify range). Anterior fontanel is soft and flat. ~~ ~ INTERVENTIONS RATIONALES Ensure that all people coming in contact with infant wash their hands well before and after touching the baby. Ensure that all equipment used for infant is sterile, scrupulously clean, or dis- posable. Do not share equipment with other infants. Place infant in isolette/iso- lation room per hospital policy (specify for agency). Maintain a neutral thermal environment. Hand washing prevents the spread of pathogens from person to person. Interventions prevent the spread of pathogens to the infant from equipment. Placing the infant in an isolette allows close obser- vation of the ill neonate and protects other infants from infection. A neutral thermal environ- ment decreases the meta- bolic needs of the infant. The ill neonate has difi- culty maintaining a stable temperature. ~~ ~~ ~ INTERVENTIONS RATIONALES Assess TPR and Blc aus- cultate breath sounds (specify frequency). Assess anterior fontanel (specify frequency) and continually observe infant for changes in activity or behaviors (e. g., feeding, sleeping, jitteriness or seizure activity, etc. ). Provide respiratory support as indicated (specify: e. g., oxyhood, ventilato,r etc. ). Feed infant as ordered (specify: e. g., breast, for- mula, OG feedings, or TPN). Provide for non- nutritive sucking if unable to breast-or bottle feed. Administer IV fluids as ordered via an infusion pump (specify: fluids, rate, site). Assess rate and site q hour. Administer antibiotics per order (specify, drugs, doses, routes and method [e. g., syringe pump], and times). Observe for adverse effects (specify for each drug). Monitor lab results as obtained (culture reports, Assessments provide infor- mation about the spread of infection. 7' heart rate and respirations, 4 B/P are signs of sepsis. Spread of infection may cause respi- ratory distress. Assessment provides infor- mation about possible spread of infection to the CNS: signs of meningitis. Respiratory support may be needed during the acute phase of infection to pre- vent additional physiologic stress. Nutritional needs may increase during infection while the infant may feed poorly. OG feedings or TPN ensure that nutrient needs are met if the infant is too ill to suck effectively. IV fluids help maintain fluid balance. An infusion pump, hourly I&O, and site assessment help pre- vent complications of ther- apy: FVE, infiltration, and infection. (Specih action of each drug. Specify adverse effects. ) Lab results provide infor- mation about the pathogen and infant's | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 289 INTERVENTIONS RATIONALES CBC, differential, CRP, electrolytes, drug peak and trough, etc. ). Notify care- giver of abnormal findings. Assess hourly intake and output and daily weight. Assess urine specific gravi- ty q 8 hours. Monitor infant for hypo- glycemia, jaundice, devel- opment of thrush, or signs of bleeding (petechiae, occult blood in stools). Teach parents effective handwashing techniques. Encourage participation in caring for their infant. response to illness and treatment. Interventions provide information about infant's fluid balance. Assessments provide infor- mation about development of complications of infec- tion: hypoglycemia, hyper- bilirubinemia, opportunis- tic infections, and coagula- tion deficits/DIC. Teaching parents helps prevent the spread of infection during hospital- ization and at home. Participation in care pro- motes bonding and devel- opment of the parenting role. Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (What is infant's heart rate? respiratory rate? Is anterior fontanel flat and soft?) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |