Nursing Care Plan Preterm Infant | Risk for Impaired Skin Integrity

Nursing diagnosis: Risk for impaired skin integrity may be related tothin skin, fragile capillaries near the skin surface, absence of subcutaneous fat over bony prominences, inability to change positions to relieve pressure points, use of restraints (protecting invasive lines/tubes), alterations in nutritional state.

Desired Outcomes: Maintain intact skin. Be free of dermal injury.

Nursing intervention with rationale:
1. Inspect skin, noting areas of redness or pressure.
Rationale: Identifies areas of potential dermal breakdown, which can result in sepsis.

2. Provide mouth care using saline or glycerin swabs. Apply petroleum jelly to lips.
Rationale: Helps prevent drying and cracking of lips associated with absence of oral intake or the drying effects of oxygen therapy.

3. Avoid application of harsh topical agents; carefully wash off povidone-iodine solutions after procedures.
Rationale: Helps prevent skin breakdown and loss of protective epidermal barrier.

4. Provide range-of-motion exercises, routine position changes, and fleece or flotation pad.
Rationale: Helps prevent possible necrosis related to edema of dermis or lack of subcutaneous fat over bony prominences.

5. Minimize use of tape to secure tubes, electrodes, urine bags, IV lines, and so forth.
Rationale: Removal of tape may accidentally remove epidermal layer, because cohesion is stronger between tape and stratum corneum than between dermis and epidermis.

6. Bathe infant using sterile water and mild soap. Wash only grossly soiled body parts. Minimize manipulation of infant’s skin.
Rationale: After 4 days, skin develops some bactericidal properties because of acid pH. Frequent bathing using alkaline soaps or moisturizers may raise skin pH, compromising normal flora and natural defense mechanisms that protect against invading pathogens.

7. Change electrodes only when necessary.
Rationale: Frequent changing may contribute to skin irritation/dermal injury.

8. Apply antibiotic ointment to nares, mouth, and lips if they are cracked or irritated.
Rationale: Promotes healing of lesions associated with administration of oxygen; reduces risk of infection.

Nursing Care Plan Preterm Infant | Fluid Volume Deficit

Nursing diagnosis: Fluid volume deficit may be related to extremes of age and weight (premature, under 2500 g), excessive fluid losses (thin skin, lack of insulating fat, increased environmental temperature, immature kidney/failure to concentrate urine).

Desired Outcomes: Be free of signs of dehydration or glycosuria with fluid intake approximating output and pH, Hct, and urine specific gravity WNL. Display weight gain of 20–30 g/day.

Nursing intervention with rationale:
1. Obtain daily serial weights using same scale at same time of day.
Rationale: Weight is the most sensitive indicator of fluid balance. Weight loss should not exceed 15% of total body weight or 1%–2% of total body weight per day. Inadequate weight gain may be related to water imbalance or inadequate caloric intake.

2. Calculate fluid balance (total intake minus total output) each shift and cumulative balance each 24-hr period. Maintain hourly records of infusing IV fluids/feedings. Determine output through measuring urine from collecting bag or through weighing/counting diapers. Also record amount of blood taken for laboratory testing.
Rationale: Output should be 1–3 ml/kg/hr, while fluid therapy needs are approximately 80–100 ml/kg/day on the 1st day of life, increasing to 120–140 ml/kg/day by the 3rd day after delivery. Lower gestational age has a negative impact on the glomerular filtration rate (GFR) and is further limited by conditions that impair renal blood flow or oxygen content (e.g., dehydration, respiratory distress), often resulting in oliguria/anuria. Positive fluid balance and corresponding weight gain in excess of 20–30 g/day suggest fluid excess.

3. Measure urine specific gravity after each voiding, or every 2–4 hr, by aspirating urine from diaper if infant cannot tolerate adhesive or urine collecting bag.
Rationale: Although renal immaturity and inability to concentrate urine usually result in low specific gravity in the preterm infant (normal range is 1.006–1.013), urine specific gravity may vary, providing an indication of the level of hydration. Low levels indicate excessive fluid volume; levels >1.013 indicate insufficient fluid intake and dehydration.

4. Test urine with Dextrostix per protocol.
Rationale: Even in cases of hypoglycemia, glycosuria occurs as immature kidneys begin excreting glucose, which may lead to osmotic diuresis, increasing risk of dehydration.

5. Minimize insensible fluid losses through use of clothing, thermoneutral temperatures, and warm or humidified oxygen.
Rationale: Preterm infant loses large amounts of water through skin, because blood vessels are close to surface and insulating fat levels are decreased or absent. Phototherapy or use of radiant warmer may increase insensible losses by 50%, necessitating increased intake to as much as 200 ml/kg/day. Note: Infants weighing <1500 g (3 lb 5 oz) are most susceptible to insensible fluid losses.

6. Monitor BP, pulse, and mean arterial pressure (MAP).
Rationale: A loss of 25% of blood volume results in shock, with MAP of less than 25 mm Hg indicating hypotension. Note: BP is related to weight, that is, the smaller the baby, the lower the MAP.

7. Evaluate skin turgor, mucous membranes, and status of anterior fontanel.
Rationale: Fluid reserves are limited in the preterm infant. Minimal fluid losses/shifts can quickly lead to dehydration, as noted by poor skin turgor, dry mucous membranes, and depressed (sunken) fontanels.

8. Note lethargy, high-pitched cry, abdominal distension, increased apnea, twitching, hypotonia, or seizure activity.
Rationale: These signs reflect hypocalcemia, which is most likely to occur during the first 10 days of life.

9. Assess IV site every hour. Note edema or failure of fluid infusion. Do not check needle position by lowering fluid below needle level.
Rationale: Swelling may indicate that infiltration of fluid is occurring or that tape is too tight. Back-up of blood caused by lowering fluid may clog needle.

10. Administer potassium chloride, 10% calcium gluconate, and 50% magnesium sulfate, as indicated. Monitor infant for potential bradycardia via cardiac monitor; observe infusion site for signs of irritation or edema.
Rationale: Correction of electrolyte imbalances is necessary to maintain or achieve homeostasis. Calcium administered through umbilical venous catheter may cause liver necrosis; if administered through umbilical artery, it may contribute to NEC. Early recognition and prompt intervention may limit untoward effects of infiltration of medication, such as sloughing, calcification, and necrosis. Note: Calcium replacement is ineffective in presence of magnesium deficit.

Nursing Care Plan Preterm Infant | Risk for Disorganized Infant Behavior

Nursing diagnosis: Risk for disorganized infant behavior may be related to prematurity (immaturity of CNS system, hypoxia), environmental overstimulation, invasive/painful procedures and therapies, separation from parent(s).

Desired Outcomes: Exhibit organized behaviors that allow the achievement of optimal potential for growth and development as evidenced by modulation of physiological, motor, state, and attentional-interactive functioning.

Nursing intervention rationale:
1. Determine infant’s chronological and develop mental age; note length of gestation. Assess individual behaviors using appropriate tool (e.g., assessment of Preterm Infant Behavior Scale).
Rationale: Useful in choosing interventions to meet specific needs of infant and reduce detrimental environmental stimuli. The APIB scale measures five areas of developmental behaviors, autonomic, motor control, state differentiation, attention maintenance and social interaction, self-regulation.

2. Provide a primary nurse for each shift. (Assign one primary nurse per baby to provide information to parents.)
Rationale: Promotes continuity of care and follow-through with developmental program. Enhances recognition of subtle changes in infant’s behavior and condition. Consistent and predictable care enables infant to develop trust in caregiver, environment, and self and facilitates coping. Multiple caretakers confuse the infant, increase distress during feeding, cause irritability, and upset usual attention. Note: Having one nurse responsible for giving information helps to reduce instances of parents’ being uninformed or misunderstanding.

3. Create womblike atmosphere whenever possible by covering Isolette for extended periods, playing recorded placental or maternal heart sounds, and surrounding infant with rolled blankets or manufactured “nesting” device.
Rationale: Providing dark, quiet environment reduces stress, promotes adaptation, and has been found to correlate positively with weight gain, early weaning from oxygen or ventilators, and earlier discharge. Recorded maternal heart sounds tend to reduce or eliminate infant’s perception of noise from the Isolette. Nesting position facilitates hand-to-mouth behavior for self-consoling.

4. Cover top of radiant warmer with plastic wrap, if appropriate.
Rationale: Reduces environmental stress from air currents, which startle the infant as personnel move past the warmer.

5. Reposition infant using rolled diapers placed at the back and front, if infant is in lateral position, or at sides, if infant can tolerate a prone position.
Rationale: Neuromuscular immaturity can impair infant’s ability to seek a position of comfort or to relieve stress through repositioning. Rolled diapers surrounding baby provide a sense of security and have a calming effect. Prone position promotes sleep and optimal relaxation.

6. Change infant’s position periodically (especially if infant has nasal CPAP or endotracheal tube).
Rationale: Provides kinesthetic stimulation. Neuromuscularly immature infant is unable to reposition self or move about in the Isolette.

7. Interact with infant at face level (en face interaction), allowing eye contact. Provide colorful linens and changing designs or pictures on side of incubator, and encourage parents to make mobiles of construction paper and string once infant reaches postconception age of 40 wk.
Rationale: Visual stimulation is best provided by objects placed 7–9 in from face. Black and white faces and a checkerboard design promote visual attention. Infant may become habituated to stimuli that do not change. Involving parents in creating stimuli for infant helps ensure that the process continues after discharge.

8. Hold infant in ventral position (e.g., baby held to shoulder to burp) when possible, uncover eyes periodically if infant is receiving phototherapy.
Rationale: Enhances visual stimulation/orientation.

9. Assess infant for physiological signs/behavioral cues indicating stress (e.g., apnea, color change, bradycardia, sneezing, yawning), irritability or apathy, change in muscle tension, disorganized motor activity and sleep-wake cycles, measured change in sensory acuity), noting causative factors and eliminating or reducing stressors when possible.
Rationale: Disorganization of the autonomic system is often associated with prematurity, resulting in some infants lacking the developmental capability of dealing with more than one sensory input at a time. Familiarity with the infant’s usual behavioral responses and personality traits is necessary for identifying subtle changes that indicate stress and the need for intervention to modify causative factors.

10. Provide rocking or water beds, if indicated.
Rationale: Kinesthetic stimulation in preterm infants of 34 weeks’ gestation has been shown to improve sleep, decrease heart rate, reduce frequency of state changes, and increase head size and biparietal diameter.

Nursing Care Plan Preterm Infant | Risk for CNS Damage Injury

Nursing diagnosis: Risk for CNS damage injury may be related to tissue hypoxia, altered clotting factors, metabolic imbalances (hypoglycemia, electrolyte shifts, elevated bilirubin).

Desired Outcomes: Be free of seizures and signs of CNS impairment. Maintain homeostasis, as evidenced by ABGs; serum glucose, electrolytes, and bilirubin levels WNL.

Nursing intervention with rationale:
1. Assess respiratory effort. Note presence of pallor or cyanosis.
Rationale: Respiratory distress and hypoxia affect cerebral function and may damage or weaken walls of cerebral blood vessels, increasing risk of rupture. If untreated, hypoxia may result in permanent damage.

2. Monitor Dextrostix levels, and observe infant for behaviors indicating hypocalcemia or hypoglycemia (such as convulsions, twitching, myoclonic jerks, or eye rolling.)
Rationale: Because of its demands for glucose, the brain may suffer irreparable damage when serum glucose levels are lower than 30–40 mg/dl. Hypocalcemia (serum calcium levels 7 mg/dl) often accompanies hypoglycemia and may result in apnea and seizures.

3. Observe infant for alterations in CNS function, as manifested by behavior changes, lethargy, hypotonia, bulging or tense fontanel, eye rolling, or seizure activity. Investigate deteriorating status indicated by high-pitched cry, labored respirations, and cyanosis, followed by apnea, flaccid quadriparesis, unresponsiveness, hypotension, tonic posturing, and areflexia.
Rationale: Birth trauma, fragile capillaries, and impaired coagulation processes place preterm infant at risk for IVH, especially those infants weighing 1500 g or under 34 weeks’ gestation. Tense or bulging anterior fontanel may be first sign of IVH, hemorrhagic shock, or increased intracranial pressure (IICP), which can easily lead to death from circulatory collapse. Infant of 32 weeks’ gestation may become lethargic or hypotonic and may manifest uncontrolled “roving-eye” movements and lack of visual tracking. Note: Clinical signs of developing IVH may be absent, very subtle, or sudden and life-threatening.

4. Measure head circumference, as indicated.
Rationale: Helps detect possible IICP or hydrocephalus, which may be a sequela of subdural hemorrhage. Only 35%–50% of infants with hydrocephalus develop normally.

5. Assess skin color, noting evidence of increasing jaundice associated with behavior changes such as lethargy, hyperreflexia, convulsions, and opisthotonos.
Rationale: Preterm infant is more susceptible to kernicterus at lower serum bilirubin levels than full-term infant because of increased levels of unconjugated circulating bilirubin crossing the blood-brain barrier.

6. Monitor Hb/Hct; ABGs.
Rationale: Lowered Hb levels or anemia reduce oxygen carrying
capacity, increasing risk of permanent CNS damage associated with hypoxemia. Abrupt fall in Hct may be first indicator of IVH. Note: Pulse oximetry may be used to monitor O2 level routinely with periodic ABGs to monitor other parameters of acid/base balance.

7. Monitor Bilirubin levels.
Rationale: Rapidly rising levels may result in kernicterus if not treated promptly.

8. Provide supplemental oxygen.
Rationale: Hypoxemia increases the risk of impairment or permanent CNS damage.

9. Administer Phenytoin or diazepam (Valium).
Rationale: May be used if other antiepileptic drugs are not successful in controlling seizure activity. Note: Dosage should be based on blood levels.

10. Assist with fluid replacement or maintain restrictions, as appropriate.
Rationale: Cerebral perfusion depends on adequate circulatory volume. Note: Fluids may need to be restricted in cases of hypertonicity, CNS damage with bleeding, or cerebral palsy.

Nursing Care Plan Preterm Infant | Risk for Infection

Nursing diagnosis: Risk for infection may be related to immature immune response, fragile skin, trauma-tized tissues, invasive procedures, environmental exposure (PROM, transplacental exposure).

Desired Outcomes: Be free of signs of infection, for example, temperature instability, lethargy, respiratory distress, purulent drainage/secretions. Maintain negative serum, CSF, urine, and nasopharyngeal cultures with CBC, platelets, and pH level WNL.

Nursing intervention with rationale:
1. Review record of delivery to determine whether resuscitative measures were required, length of rupture of membranes, and presence of chorioamnionitis. Note maternal GBS status and/or other sexually transmitted diseases (STDs) present.
Rationale: Infant who has been resuscitated and has required invasive interventions is especially prone to introduction of pathogens and infection. Maternal factors such as PROM with preterm labor and delivery possibly caused by an infectious process predispose the preterm infant to ascending infection. Early-onset sepsis (occurring within the first 2 days of life) is affected by host defenses and duration of antepartal rupture of membranes. Transplacentally acquired infections (which affect two-thirds of all infected infants) are also a threat.

2. Determine gestational age of fetus, using Dubowitz criteria.
Rationale: Delivery prior to 28–30 weeks’ gestation increases infant’s susceptibility to infection, because of reduced ability of WBCs to destroy bacteria, reduced transfer of IgG (IgG is transported across the placenta primarily in the third trimester), lack of IgA if infant does not receive breast milk, and poorly keratinized skin with ineffective barrier qualities. Note: Infant who suffers from intrauterine growth retardation/restriction is at greater risk for infection.

3. Promote meticulous hand washing by staff, parents, and ancillary workers per protocol. Use antiseptic before assisting with surgical or invasive procedure.
Rationale: Hand washing is the most important practice for preventing cross-contamination and controlling infection in the nursery.

4. Monitor staff and visitors for presence of skin lesions, draining wounds, acute respiratory infections, fever, gastroenteritis, active herpes simplex (oral, genital, or paronychial), and herpes zoster.
Rationale: Transmission of disease to neonate by employees or visitors can occur directly or indirectly.

5. Provide adequate space between infants or between Isolettes or individual units. Use separate isolation rooms and isolation technique, as indicated.
Rationale: Providing 4–6 ft of space between infants helps prevent spread of droplet or airborne infections.

6. Assess infant for signs of infection, such as temperature instability (hypothermia or hyperthermia), lethargy or behavior changes, respiratory distress (apnea, cyanosis, or tachypnea), jaundice, petechiae, nasal congestion, or drainage from eyes or umbilicus.
Rationale: Useful in the diagnosis of infection; body temperature alone is an unreliable means of assessing infection in the preterm infant with impaired inflammatory response and WBC mobilization.

7. Establish a cohort of infants, when possible, and ensure that same nurse cares for the infants grouped together.
Rationale: Infants who are born within the same time frame (usually 24–48 hr), or who are colonized/infected with the same pathogen, may be grouped together until discharge. Such grouping is an important measure in infection control in that it limits the amount of contact of one infant with other susceptible infants or personnel.

8. Use aseptic technique during suctioning. Date the opened solution for humidification, irrigation, or nebulization, and discard after 24 hr. Ensure routine cleaning or replacement of respiratory equipment.
Rationale: Reduces opportunity for introduction of bacteria that could result in respiratory infection.

9. Observe for signs of shock or DIC, such as bradycardia, decreasing BP, temperature instability, listlessness, edema, or erythema of abdominal wall.
Rationale: DIC may occur with gram-negative septicemia.

10. Administer antibiotics IV based on results of culture and sensitivity.
Rationale: Broad-spectrum antibiotic coverage with ampicillin and an aminoglycoside is usually initiated, pending results of culture and sensitivity tests. Indiscriminate or inappropriate use of systemic antibiotics may cause undesirable side effects, foster emergence of resistant bacterial strains, and alter the newborn’s normal flora.