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.