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...

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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:...

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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...

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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...

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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...

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