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.

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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 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.

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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 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.

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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 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.

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Nursing Care Plan for Diverticulitis

Diverticulitis occur when fecal material becomes lodged in these pouches causing inflammation and bacterial invasion.

Nursing Diagnosis: Pain related to physical injuring agents (bacterial invasion) causing edema, irritability, spasm of colon.

Expected Outcomes: Relief or control of pain evidenced by verbalization that pain reduced or absent.

Nursing intervention with rationale:
I. Assess for:
A. Intermittent abdominal pain in left lower quadrant, cramping.
Rationale: Indicates diverticulosis.

B. Severity, type of pain, referred back pain, abdominal guarding, flexed knees, mass in left lower quadrant.
Rationale: Data for possible diverticulitis.

II. Administer:
A. Analgesic (acetaminophen, aspirin, codeine)
Rationale: Acts to reduce pain by interrupting CNS pain pathways.

B. Anticholinergic (propatheline).
Rationale: Acts to control muscle spasm.

III. Perform/Provide
A. Bedrest, reduced stimuli
Rationale: Reduces pain perception.

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Nursing Care Plan Gestational Diabetes Mellitus | Risk for Fetal Injury

Nursing Care Plan for Gestational Diabetes Mellitus

Nursing Diagnosis: Risk for fetal injury related to elevated maternal serum glucose levels, changes in circulation.

Desired Outcomes: Display normally reactive NST and negative OCT and/or CST. Be full-term, with size appropriate for gestational age.

Nursing intervention and rationale:
1. Determine White’s classification for diabetes; explain classification and significance to client/couple.
Rationale: Fetus is at less risk if White’s classification is A, B, or C. The client with classification D, E, or F who develops kidney or acidotic problems or PIH is at high risk. As a means of determining prognosis for perinatal outcome, White’s classification has been used in conjunction with (1) evaluation of diabetic control or lack of control and (2) presence or absence of Pederson’s prognostically bad signs of pregnancy (PBSP), which include acidosis, mild/severe toxemia, and pyelonephritis. The National Diabetes Data Group Classification, which includes diabetes mellitus (type I, insulin-dependent; type II, non–insulin-dependent), impaired glucose tolerance, and gestational diabetes mellitus, has not yet had prognostic significance in predicting perinatal outcomes.

2. Note client’s diabetic control before conception.
Rationale: Strict control (normal HbA1c levels) before conception helps reduce the risk of fetal mortality and congenital anomalies.

3. Assess fetal movement and FHR each visit as indicated. Encourage client to periodically count/record fetal movements beginning about 18 weeks’ gestation, then daily from 34 weeks’ gestation on.
Rationale: Fetal movement and FHR may be negatively affected when placental insufficiency and maternal ketosis occur.

4. Monitor fundal height each visit.
Rationale: Useful in identifying abnormal growth pattern (macrosomia or IUGR, small or large for gestational age [SGA/LGA]).

5. Monitor urine for ketones. Note fruity breath.
Rationale: Irreparable CNS damage or fetal death can occur as result of maternal ketonemia, especially in the third trimester.

6. Provide information and reinforce procedure for home blood glucose monitoring and diabetic management.
Rationale: Decreased fetal/newborn mortality and morbidity complications and congenital anomalies are associated with optimal FBS levels between 70 and 96 mg/dL, and 2-hr postprandial glucose level of less than 120 mg/dL. Frequent monitoring is necessary to maintain this tight range and to reduce incidence of fetal hypoglycemia or hyperglycemia.

7. Monitor for signs of pregnancy-induced hypertension (PIH) (edema, proteinuria, increased blood pressure).
Rationale: About 12%–13% of diabetic individuals develop hypertensive disorders owing to cardiovascular changes associated with diabetes. These disorders negatively affect placental perfusion and fetal status.

8. Provide information about possible effect of diabetes on fetal growth and development.
Rationale: Helps client to make informed decisions about managing regimen and may increase cooperation.

9. Review procedure and rationale for amniocentesis using L/S ratio and presence of PG.
Rationale: When maternal/placental functioning is impaired before term, fetal lung maturity is criterion used to determine whether survival is possible. Hyperinsulinemia inhibits and interferes with surfactant production; therefore, in the diabetic client, testing for presence of PG is more accurate than using L/S ratio.

10. Assist with preparation for delivery of fetus vaginally or surgically if test results indicate placental aging and insufficiency.
Rationale: Helps ensure positive outcome for neonate. Incidence of stillbirths increases significantly with gestation more than 36 wk. Macrosomia often causes dystocia with cephalopelvic disproportion (CPD).

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Nursing Care Plan Gestational Diabetes Mellitus | Risk for Maternal Injury

This nursing care plan for gestational diabetes mellitus is designed for the nursing diagnosis of risk for maternal injury may be related to changes in diabetic control, abnormal blood profile/anemia, tissue hypoxia, altered immune response.

Desired Outcomes: Remain normotensive. Maintain normoglycemia, free of signs/symptoms of ketoacidosis. Be free of complications (e.g., infection, placental separation).

Nursing intervention with rationale:
1. Note White’s classification for diabetes. Assess degree of diabetic control (Pederson’s criteria).
Rationale: Client classified as D, E, or F is at higher risk for complications, as is client with PBSP.

2. Assess client for vaginal bleeding and abdominal tenderness.
Rationale: Vascular changes associated with diabetes place client at risk for abruptio placentae.


3. Monitor for signs and symptoms of preterm labor.
Rationale: Overdistension of uterus caused by macrosomia or hydramnios may predispose client to early labor.

4. Assist client in learning home monitoring of blood glucose, to be done a minimum of 4 times/day.
Rationale: Allows greater accuracy than urine testing because renal threshold for glucose is lowered during pregnancy. Facilitates tighter control of serum glucose levels.

5. Request that client check urine for ketones daily.
Rationale: Ketonuria indicates presence of starvation state, which may negatively affect the developing fetus.

6. Identify for episodes of hyperglycemia.
Rationale: Diet/insulin regulation is necessary for normoglycemia, especially in second and third trimesters, when insulin requirements often double (may quadruple in third trimester).

7. Assess for and/or monitor presence of edema.
Rationale: Because of vascular changes, the diabetic client is prone to excess fluid retention and PIH. The severity of the vascular changes before pregnancy influences the extent and time of onset of PIH.

8. Determine fundal height; check for edema of extremities and dyspnea.
Rationale: Hydramnios occurs in 6%–25% of pregnant diabetic clients; may possibly be associated with increased fetal contribution to amniotic fluid, because hyperglycemia increases fetal urine output.

9. Instruct in insulin administration, as required. Ensure that client is adept at self-administration, either subcutaneously (SC) or with pump, depending on client’s needs or care setting.
Rationale: Insulin requirements are decreased in first trimester, then double and may even quadruple as the pregnancy progresses. Highly motivated and capable clients may do well with a continuous subcutaneous insulin infusion pump to more naturally meet insulin needs.

10. Start IV therapy with 5% dextrose; administer glucagon SC if client is hospitalized with insulin shock and is unconscious. Follow with protein-containing fluids/foods, e.g., 8 oz skim milk when client is able to swallow.
Rationale: Glucagon is a naturally occurring substance that acts on liver glycogen and converts it to glucose, which corrects hypoglycemic state. (Note: Hypertonic glucose [D50] administered IV may have negative effects on fetal brain tissue because of its hypertonic action.) Protein helps sustain normoglycemia over a longer period of time.

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Nursing Care Plan for Circumcision

Circumcision is a surgical procedure in which the prepuce (foreskin) of the penis is separated from the glans, and a portion is excised. This elective procedure is performed in the United States based on parental choice for reasons related to hygiene, religion, tradition, social norms, and culture. It is usually performed at 12–24 hr of age or when the infant is considered physically stable. Frequency of this procedure has declined in recent years to approximately 62%.


NURSING PRIORITIES
1. Provide parents with sufficient information to make an informed choice.
2. Promote comfort and healing.
3. Identify and minimize postoperative complications.
4. Instruct parent(s) in proper care of circumcised infant.

DISCHARGE CRITERIA
1. Void appropriately past procedure.
2. Free of complications.
3. Parent(s) understand care needs and signs/symptoms requiring further evaluation.

Nursing diagnosis: Acute pain related to trauma to/edema of tender tissues possibly evidenced by crying, irritability, changes in sleep pattern, refusal to eat

Desired Outcome:
1. Appear relaxed, appropriately consolable.
2. Resume normal sleeping and eating patterns.

Nursing intervention with rationale
1. Provide pacifier (dipped in sugar, if desired), stroke lightly, and talk gently to infant during procedure. Observe infant response.
Rationale: Provides distraction and sense of reassurance to soothe the infant

2. Remove infant from restraints immediately following procedure. Calm infant by holding, cuddling, dressing, and talking to him. Encourage parents to feed and cuddle infant.
Rationale: A sense of uneasiness occurs because of positioning and restraint. Acute pain occurs at the time of surgical procedure, because the foreskin contains numerous nerve endings. Change of position, freedom of movement, and tactile activities refocus infant’s attention and comfort infant. Feeding may promote relaxation. Note: Infant’s turning head away, increased restlessness, hiccuping suggest overstimulation, which may further distress the infant.

3. Apply petroleum jelly and gauze dressing loosely around glans, as appropriate. Leave in place for at least 24 hr.
Rationale: Protects against adherence to diaper and direct contact with urine.

4. Position infant on side or back, not on abdomen. Loose diaper or use no diaper at all for 24–72 hr following procedure. Note continued placement of plastic rim following circumcision with plastic bell.
Rationale: Prevents friction or pressure on the penis. Plastic rim remains in place for 5–7 days. Plastic bell falls off by itself when glans is healed. Note: Removal of the bell by the healthcare provider may be

5. Avoid use of soaps on penis; clean with clear water.
Rationale: Soap may cause irritation, increasing discomfort, and may cause plastic bell to fall off prematurely.

6. Protect the surgical site from alcohol when caring for umbilicus.
Rationale: Alcohol may cause stinging, adding to infant’s discomfort.

7. Note infant’s behavior following procedure.
Rationale: Acute pain following the procedure may last approximately 30 min, whereas discomfort related to trauma, edema, and irritation from clothing may last for up to 7 days until healing is completed.

8. Assist with dorsal penile nerve block with 1% lidocaine without epinephrine or chloroprocaine (Nesacine).
Rationale: Although it is not used routinely, anesthesia abolishes the pain and distress manifested in the

9. Apply topical agents, e.g., EMLAcream (lidocaine and prilocaine) to penis.
Rationale: Topical agent applied 1-2 hr before procedure may be as effective as nerve block without associated risks.

10. Administer acetaminophen drops as indicated.
Rationale: Helps ease acute pain, enhances effects of calming behaviors.

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Nursing Diagnosis Generalized Anxiety Disorder | Sleep Pattern Disturbance

This care plan is designed for patients with generalized anxiety disorder with a nursing diagnosis of sleep pattern disturbance may be related to psychological stress; and repetitive thoughts possibly evidenced by reports of difficulty in falling asleep/awakening earlier or later than desired; not feeling rested, and dark circles under eyes; frequent yawning.

Desired Outcomes: (1) Verbalize understanding of relationship of anxiety and sleep disturbance; (2) Identify appropriate interventions to promote sleep; and (3) Report improvement in sleep pattern, increased sense of wellbeing, and feeling well-rested.

Nursing intervention with rationale:
1. Determine type of sleep pattern disturbance present, including usual bedtime, rituals/routines, number of hours of sleep, time of arising, environmental needs, and how much of a problem it is to client.
Rationale: Identification of individual situation and degree of interference with functioning determines need for/appropriate interventions.

2. Provide quiet environment, comfort measures (e.g., back rub, wash hands/face, bath), and sleep aids, such as warm milk. Restrict use of caffeine and alcohol before bedtime.
Rationale: Promotes relaxation and cues for falling asleep. Stimulating effects of caffeine/alcohol interfere with ability to fall asleep.

3. Discuss use of relaxation techniques/thoughts, visualization.
Rationale: Promotes reduction of anxious feelings, resulting in improved sleep/rest.

4. Suggest ways to handle waking/not sleeping (e.g., do not lie in bed and think, but get up and remain inactive, or do something boring).
Rationale: Having a plan can reduce anxiety about not sleeping.

5. Involve client in exercise program, avoiding exercise within 2 hours of going to bed.
Rationale: Increases fatigue, promotes sleep but avoids excessive stimulation from activity before bedtime.

6. Avoid use of sedatives, when possible.
Rationale: Sedative drugs interfere with REM sleep and affect quality of rest. A rebound effect may lead to intense dreaming, nightmares, and more disturbed sleep.

7. Administer medications as indicated, e.g., zolpidem (Ambien).
Rationale: Although drug is recommended for short-term use only, it may be beneficial until other therapeutic interventions are successful.

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Nursing Care Plan for Seizure | Risk for Ineffective Airway Clearance |

This care plan is designed for patients suffering from seizure disorder with a nursing diagnosis of risk for ineffective airway clearance related to neuromuscular impairment; tracheobronchial obstruction; and perceptual/cognitive impairment.

Desired Outcome: Maintain effective respiratory pattern with airway patent/aspiration prevented.

Nursing intervention with rationale:
1. Encourage patient to empty mouth of dentures/foreign objects if aura occurs and to avoid chewing gum/sucking lozenges if seizures occur without warning.
Rationale: Reduces risk of aspiration/foreign bodies lodging in pharynx.

2. Place in lying position, flat surface; turn head to side during seizure activity.
Rationale: Promotes drainage of secretions; prevents tongue from obstructing airway.

3. Loosen clothing from neck/chest and abdominal areas.
Rationale: Facilitates breathing/chest expansion.

4. Insert plastic airway or soft roll as indicated and only if jaw is relaxed.
Rationale: If inserted before jaw is tightened, these devices may prevent biting of tongue and facilitate suctioning/respiratory support if required. Airway adjunct may be indicated after cessation of seizure activity if patient is unconscious and unable to maintain safe position of tongue.

5. Suction as needed.
Rationale: Reduces risk of aspiration/asphyxiation. Note: Risk of aspiration is low unless individual has eaten within the last 40 min.

6. Administer supplemental oxygen/bag ventilation as needed postictally.
Rationale: May reduce cerebral hypoxia resulting from decreased circulation/oxygenation secondary to vascular spasm during seizure. Note: Artificial ventilation during general seizure activity is of limited or no benefit because it is not possible to move air in/out of lungs during sustained contraction of respiratory musculature. As seizure abates, respiratory function will return unless a secondary problem exists (e.g., foreign body/aspiration).

7. Prepare for/assist with intubation, if indicated.
Rationale: Presence of prolonged apnea postictally may require ventilatory support.

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