Seton Hall University

College of Nursing
NUTC 3916 Clinical Weekly Careplan

General Background Information: (4 points)

Patient Initials: I.M DOA: 10/23/10 AGE: 3 Weeks old

Admitting Dx: permaturity / Respiratory distress syndrome Gender: Male DOB:

10/23/10

VS: Temp 96.5 F, HR: 140, RR: 44, B/P: 48/23, B/P Mean: 32, O2 stats: 97, Birth
weight: 530 gram, Pain: 0/10 Numeric scale

Chief Complaint: (4 points)

“Prematurely at 24 weeks old with respiratory distress syndrome”

Present Health or History of Present Illness: (4 points)

Pt was admitted to the NICU few minute after birth, because he was born prematurely at
24 weeks old with respiratory distress syndrome. Pt arrived to NICU with no spontaneous
respiratory effort, no movement, pt was administered PPV and heart rate was still 60.
Chest compression started and pt was intubated with a 2-5 ett, pt was also giving
epinephrine 0.1ml via ETT which increased and stabilized his heart rate to 140.
Umbilical artery catheter inserted, a sepsis evaluation was done and antibiotic
administered and Pt was placed oscillator vent on 10/23/10. Pt seem stable and
progressive, his vital are with in normal limit.

Past Medical History: (include illness, surgery, birth history, injuries, hospitalizations,
immunizations & allergies) (4 points)

Pt was born prematurely with respiratory distress syndrome. Pt’s mother was admitted at
23 weeks gestation with history of pre eclampsia and was given steroids and discharged,
she was later re admitted on 10/23/10 with severe epigastric pain and proteinuria. An
emergent c-section was performed for sever pre eclampsia. Pt mum was induced at 37
weeks during first pregnancy for per eclampsia.
Significant Social History: (living arrangements, school, daycare, family) (4 points)

Pt will leave at home with parents and one sibling. Parents deny smoking, drinking or use
of recreational drug by them and any other family member. The family owns no pets.

Signicicant Family History: (Familial risk factors) (4 points)

Mother has history of pre eclampsia during pregnancy; brother was born prematurely
with heart problem and father’s disease not reported. Patient’s grandmother is alive and
presently has hypertension. Grandfather is living and also suffers from arthritis, which
presently affects his mobility. Parents deny any familial risk factor such as abuse,
violence or neglect.

Treatments, Tests and Procedures: (4 points)

 Complete blood count (CBC) to measure the level of different cells in your baby’s
blood
 Newborns screening tests to check for some inherited disorders such as PKU and
cystic fibrosis
 Anterior Blood gases to check levels of oxygen, carbon dioxide, and acids in the
blood
 Blood cultures and C-reactive protein to help check for infection
 Chemical (electrolyte) balance to monitor electrolyte imbalance
 Blood transfusion to replace decreased RBC levels due to prematurity
 Blood sugar (glucose) level to monitor drop in glucose level
 Bilirubin level to check for jaundice
 X-ray done to see the condition of the lungs and other organs, and check the positions
of any tubes, catheters.
 Hemoglobin/Hematocrit to check for anemia
 Oscillator vent started 10/23/10 to promote effective breathing.
Lab Results: (12 points)

WBS(5.0 -17.5) HGB (11.3-13.4) PLT(14O-450)

Pt.:14.0k/cmm Pt.14.0g/dl Pt. 192k/cmm
normal abnormal Normal

Na(136-145) Cl-(96-108) Bun:(10-26) Glu(65-109)

Pt. 137meq/l Pt.108 meq Pt:11meg/d Pt: 50mg/d
normal normal Normal Normal
K (3.5-5.0) Co2(24-30) Creat(0.50-1.20)
Pt. 5.0meg/c Pt. 41mmhg Pt. 0.02mg/dl
normal abnormal Normal
Interpretation:

WBC normal range 4.5 to 14.5 WBC is within normal range

HGB normal range 11.5- 15.5 g/dl , HGB is within normal range.
PLT normal range of 140- 440, Pt’s PLT is within normal range.
HCT normal range of 35.0 -45.0%.
NA normal range of 135-145,
Cl- normal range of 98 -108,
BUN normal range of 6-23
K+ normal range of 3.5-5.0 C02 normal range of 41 because pt has respiratory acidosis
Creat normal range of 0.02 because pt organs are under developed.

Current Medications:(8 points)

Medication/Dose Purpose Side Effects Nursing Implications

Name (generic and brand name); vancomycin 5mg in d5w, infusing over 60minat 1.6
ml/hr q18h,
Drug Class: Antibiotic
Purpose: indicated for the treatment of serious or severe infections caused by susceptible
strains of methicillin-resistant (beta-lactam-resistant) staphylococci. it is used to treat
staphylococcal endocarditis septicemia, bone infections, lower respiratory tract
infections, skin and skin structure infections
Side effect: Rapid infusion may also cause flushing of the upper body (“red neck”) or
pain and muscle spasm of the chest and back, wheezing, dyspnea, uriticaria. Renal
failure, Ototoxicity, Phlebitis and neutropenia
Nursing implication Skipping doses or not completing the full course of therapy may (1)
decrease the effectiveness of the immediate treatment and (2) increase the likelihood that
bacteria will develop resistance and will not be treatable by vancomycin or other
antibacterial drugs in the future. Diarrhea is a common problem caused by antibiotics
which usually ends when the antibiotic is discontinued

Name fluconazole Diflucan 2mg in d5w, infusing over 30minat 1.6 ml/hr Wednesday
Drug Class: Antifungal
Purpose: Fluconazole is used to treat fungal infections, including yeast infections of the
vagina, mouth, throat, esophagus (tube leading from the mouth to the stomach), abdomen
(area between the chest and waist), lungs, blood, and other organs and to treat meningitis
(infection of the membranes covering the brain and spine) caused by fungus.
Side effect: headache, dizziness, diarrhea, stomach pain, heartburn. Change in ability to
taste food, nausea, extreme tiredness, unusual bruising or bleeding, lack of energy, loss of
appetite, pain in the upper right part of the stomach yellowing of the skin or eyes
Nursing implication: Do not take cisapride (Propulsid) while taking fluconazole,

Name; Ceftazidime 40 mg in d5w, infusing over 30minat 0.8 ml/hr q18h,

Drug Class: Antibiotic third generation Cephalosporin
Purpose: To treat infection due to gram-negative anaerobic bacteria such has respiratory
tract, GU tract, and prophylactic for surgical procedures.
Side effect: Anaphylactic reaction to penicillin, hypersensitivity to cephalosporin, such has
hives, rash, low BP, increased respiration.
Nursing implication: Complete antibiotic therapy for full length of treatment. Notify doctor if
fever persist and is above 100.6f. Teach Pt for iv discomfort when on this med.

Name vitamin A (Retinol) 5000 units ml IM

Drug Class: Vitamin
Purpose: anti-infective vitamin, play a central role in the development WBC, Preserve
and improve your eyesight
Side effect: loss of appetite, irritability, fatigue, weakness and vomiting, include growth
retardation of the long bones in infants and toddler, dry and itchy skin, dry and brittle
fingernails, hair loss, headaches, visual changes, bone and muscle pain, fatigue,
irritability, depression, fever, liver damage, anemia,.
Nursing implication: do not take more than 5000 unit per day; tell HCP if you are taking
other over the contract supplement

IVF/Diet/Activity:(4 points)

- Pt’s is on IV fluid 10% dextrose 500ml infusing at 3-6 ml/hr on left arm hand
- IV site is good, not infiltrated.
- Pt is in place in the nesting position in secured isolette
- Pt is NPO because pt is intubated.

Physical Assessment: (8 points)

Neuro:. Pt is Alert, eye remain fused, small size head, head circumference is 20.5
unable to elicit audible, cry or freely turn head, face was symmetrical, infant reflexes no
present
Resp.: pt is on oscillator vent, breathing rapid and irregular, metabolic acidosis, lung
field are mildly hazy with good expansion,. Mild substernal retraction present, intubated
with equal chest excursion. Breathe sound clear and equal bilaterally
Cardiac: S1and S2 present, heart sound clear and normal. No S3 and S4 or murmurs
detected. Pulses are strong and equal, BP slightly high, color pink, brisk capillary refill
GI: Abdomen is round and soft; Bowel sounds are present in all 4 quadrants. No
tenderness to palpitation, no mass present, pt is intubated and NPO
GU: Patient has no pain; patient’s urine color was clear, no deviation, no distention in
abdomen, no odor present.
Vascular/Skin/Extremities: Skin is dry, flaky, and warm to touch. it is pink, shiny and
well perfuse. Skin abrasion located on right abdomen and left ankle is healing. Chest
tube is dry and intact with serosanguenus drainage on gauze. Picc line site on left arm
is intact and dry. No deformities noted.
Psychosocial : pt can respond to things he sees and hears.

Path physiology: (5 points) Neonatal RDS occurs in infants whose lungs have not yet
fully developed. The disease is mainly caused by a lack of a slippery, protective
substance called surfactant, which helps the lungs inflate with air and keeps the air sacs
from collapsing. This substance normally appears in mature lungs. It can also be the
result of genetic problems with lung development. The earlier a baby is born, the less
developed the lungs are and the higher the chance of neonatal RDS. Most cases are seen
in babies born before 28 weeks. It is very uncommon in infants born full-term (at 40
weeks).
The risk of neontal RDS may be decreased if the pregnant mother has chronic,
pregnancy-related high blood pressure or prolonged rupture of membranes, because the
stress of these situations cause the infant's lungs to mature sooner. The symptoms usually
appear within minutes of birth, although they may not be seen for several hours.
Symptoms may include : Bluish color of the skin and mucus membranes (cyanosis),
Brief stop in breathing (apnea), Decreased urine output, Grunting, Nasal flaring, Puffy or
swollen arms or legs, Rapid breathing, Shallow breathing, Shortness of breath and
grunting sounds while breathing, Unusual breathing movement -- drawing back of the
chest muscles with breathing.
High-risk and premature infants require prompt attention by a neonatal
resuscitation team. .Infants will be given warm, moist oxygen. This is critically
important, but needs to be given carefully to reduce the side effects associated with too
much oxygen. There are a number of different types of breathing machines available.
However, the devices can damage fragile lung tissues, and breathing machines should be
avoided or limited when possible. A treatment called continuous positive airway pressure
(CPAP) that delivers slightly pressurized air through the nose can help keep the airways
open and may prevent the need for a breathing machine for many babies. Even with
CPAP, oxygen and pressure will be reduced as soon as possible to prevent side effects
associated with excessive oxygen or pressure. oxide. It is important that all babies with
RDS receive excellent supportive care, including the following, which help reduce the
infant's oxygen needs: Few disturbances, Gentle handling, Maintaining ideal body
temperature. Infants with RDS also need careful fluid management and close attention to
other situations, such as infections, if they develop. www.prematurebaby.ie

Developmental Milestones/Anticipatory Guidance/Teaching needs: (5 points)

• Growth: Pt has poor feeding and nutrition problems because his inability to suck,
swallow, root and control tongue. Most infant reflexes are not present. Both his
Posterior fontanel and anterior fontanel are still open. Head size is very small and
weight gain is less than 5 oz per week.
• Heart and lungs: pt is breathing through an Oscillator vent, because lungs are not
fully developed and has little surfactant production, put Pt at very great risk of RDS
and BPD

• Motor system: Pt’s motor skills are under developed, his limbs are often kept
extended, unlike full-term babies whose arms and legs are often bent. He might
have delayed developmental ability such sitting, walking, running, and talking
later.

Anticipatory Guidance/Teaching needs:

• Teach parent to practices rear facing car seat until 20 lbs and 1 years in middle of
back seat of car
• Teach parent to always keep Side Rail of crib up
• Teach parent never to leave pt unattended on table, bed, bath
• Always Check temp of bath water, formula, foods before use
• Avoid bottles feeding at naps or bedtime
• Learn how to perform Neonatal CPR
• Teach parent sign of respiratory distress and effective intervention.

Cultural Assessment: (5 points)

Pt’s is Spanish American. Spanish people are mostly are Christian (traditionally
Catholic). They might pray or say the rosary when a loved one is ill. Many have a deep
respect for the Virgin Mary. They often wear crucifix necklaces on their infants and
toddlers, and sometime piece of thread in a little ball on their infants and toddlers
forehead. These religious practices should be acknowledged and accommodated by the
hospital and all their staff.

Discharge Planning: (5 points)

• To reduce the risk of giving your baby an infection, everyone should wash hands
properly before touching the baby.
 • Avoid visit to public places with preemies, and limit visitors to your home
• Expect your preemie to sleep more than a full-term baby, but for shorter periods.
Pt should be put to sleep on his backs to reduce the risk of sudden infant death
syndrome (SIDS).
• Most preemies need 8 to 10 feedings a day with no more than 4 hours between
each to avoid dehydration.
• Follow and complete all immunization, especially RSV vaccine
• Complete all well and health promotion visit to health care professionals.
• Contact HCP immediately if pt has SOD, apnea, or pauses in breathing, cyanosis
or Respiratory distress.
• Keep pt warm at all time.

SUBJECTIVE DATA:
Mother said “My son is a 27 week old preemies and he is have many difficulties
breathing”

OBJECTIVE DATA:
Pt is seem stable with vital indicating temp 96.5 F, HR: 140, RR: 44, B/P: 48/23, B/P
Mean: 32, O2 stats: 97, Birth weight: 530 gram
Pain 0/10. FLACC assessment scale was used. Pt seems better today as evidence stable
B/P and some weight gain.

NURSING DIAGNOSES:
IMPAIRED GAS EXCHANGE related to inadequate surfactant levels; as evidenced by
grunting, flaring, substernal and intercostals retractions

OUTCOMES
 Patient will demonstrate improved ventilation and adequate oxygenation as
evidenced by blood gas level within normal parameters for clients.
 Patient will maintain clear lung fields and remain free of signs of respiratory
distress

INTERVENTION:
Monitor respiratory rate, depth and effort, including use of accessory muscle, nasal
flaring and abnormal breathing patterns.
RATIONALE:
Increased respiratory rate, use of accessory muscles, nasal flaring, and abdominal
breathing may indicate hypoxia (Ackley 2008)

INTERVENTION:
Auscultate breath sounds every 1 to 2 hours. The presence of crackles and wheezes may
alert the nurse to airway obstruction, which may lead to or exacerbate existing hypoxia

RATIONALE:
In severe exacerbation lung sounds may be diminished or distant with air trappings.
(Zampella, 2003)
INTERVENTION:
Monitor oxygen saturation continuously by pulse oximetry. Note blood gas results as
available.
RATIONALE:
An oxygen saturation of less than 90%(normal, 95% to 100%) or a Pa02 of less than
80mm Hg (normal,80 to100 mm Hg) indicates significant oxygenation problems.( Clark,
Giuliano & Chen, 2006)

INTERVENTION:
Observe for cyanosis of the skin; especially note color of tongue and oral mucous
membrane.
RATIONALE:
Central cyanosis of the tongue and oral mucosa is indicative of serious hypoxia and is a
medical emergency. Peripheral cyanosis in the extremities may or may not be serious.
(Kasper, 2005).

INTERVENTION:
Monitor fluid intake and output; weigh infant as indicated by protocol.

RATIONALE:
Dehydration impairs ability to clear airways indicated by protocol. Because mucus
becomes thickened. Over hydration may contribute to alveolar infiltrates/pulmonary
edema. Weight loss and increased urine output may indicate diuretic phase of RDS,
usually beginning at 72–96 hr and preceding resolution of condition. (Ackley 2008)

NURSING DIAGNOSES
INEFFECTIVE THERMOREGULATION related to prematurity and low birth weight;
as evidenced by poor flexion and lack of subcutaneous fat stores needed for non shivering
thermogenesis

OUTCOMES:
 Patient will maintain temperature within normal range.
 Monitor patient for symptoms of hypothermia or hyperthermia

INTERVENTION:
Take vital signs every 1 to 4 hours, noting changes associated with hypothermia; first,
increased blood pressure, pulse and respirations, then decreased values as hypothermia
progress
RATIONALE:
Mild hypothermia activates the sympathetic nervous system, which can increase the level
of vital signs, as hypothermia progresses, the heart becomes suppressed with decreased
cardiac output and lowering of vital sign reading.(Ruffolo. 2002; Kasper et al, 2005)
INTERVENTION:
Maintain a consistent room temperature
RATIONALE:
A consistent room temperature limits environmental effect on thermoregulation. (Elliott,
2004)

INTERVENTION:
Note changes in vital signs associated with hyperthermia: rapid, bounding pulse;
increased respiratory rate and decreased blood pressure.
RATIONALE:
Consistent monitoring promotes prevention and early intervention in client with altered
cardiopulmonary status associated with hypothermia or hyperthermia. (Ackley 2008)

INTERVENTION:
Recognize that pediatric clients have a decreased ability to adapt to temperature
extremes. Take the following action to maintain body temperature in infant, keep the
head covered, keep the room temperature at 72F (22 C), use blankets to keep the client
warm.
RATIONALE:
The combination of a relatively larger body surface area, smaller body fluids volume, less
well developed temperature control mechanisms, and smaller amount of protective body
fat limits the infant’s ability to maintain normal temperature.( Hockenberry, 20050

INTERVENTION:
Recognize that infant is vulnerable to heat stroke an hot weather and ensure they receive
sufficient fluids and are protected from hot environments.
RATIONALE
Infant and young children are at risk for heat stroke for many reasons, including a
decreased thermoregulatory ability in their young body and the inability to obtain their
own fluids. ( Carroll, 2002)
 Reference
Ackley, Betty J., Ladwig, Gail B. (2008). Nursing Diagnosis Handbook. An Evidence

Baset Guide to Planning Care. Philadelphia PA: Mosby Inc.