OB Concept Map

Pathophysiology : Alteration in Pathophysiology thermoregulation. The preterm infant has a high ratio of body surface to body weight (the body's ability to produce heat is much less than than the potential for losing heat. In addition the preterm infant has very little subcutaneous fat. Without adequate insulation heat is easily lost from the core of  the body to the body surface. Also, the preterm infant has thinner , more permeable skin . The position of extension that preterm babies lie in also exposes them to more heat loss.

Outcomes:

Interventions and Rationales: Rationales:

The infant will not show signs/symptoms of  hypothermia AEB axillary temperature maintenance of 36.4-37.2 C as well as no

1.) Observe for signs and symptoms of cold stress such as decreased temperature, lethargy, and pallor. Rationale: hypothermia is associated associated with premature newborns due to decreased stores of  brown fat.

°

signs or symptoms of respiratory distress during my shift.

2.) Provide a neutral thermal environment using a servo control skin probe. probe. Rationale: the skin probe measures the infant's core temperature temperature and adjusts the incubator accordingly. accordingly. 3.) Allow skin-to-skin contact between mother and newborn. Rationale: maintains warmth of  infant and fosters security and bonding. Related lab tests and treatments:

Nursing Diagnosis: Ineffecctive thermoregulation r/t hypothermia secondary to decreased glycogen and brown fat stores.

Evaluation: Goal met: patient's temperature remained stable at 36.2 C during my shift. °

Assessment: Temperature was 36.2 C; °

Medications:

Respiratory Distress Syndrome:

Outcomes: Rel. lab tests and treatments: (6/11/12) CXR: overinflated lungs, pneumothorax resolved suctioning as needed

The infant will maintain adequate respiratory gas exchange AEB: respirations of 30-60/min; pulse oximetry readings above 83%; ABG's within normal limits, and show no signs of respiratory distress by time of  discharge.

CO2: 17 mmol/l (13-29 mmol/l)

Pathophysiology: A condition associated with prematurity resulting in a deficiency of functioning lung surfactant. Without surfactant the lung collapses after every expiration and reinflates with great difficulty , requiring the newborn to generate intense pressures with every breath.

Ca: 11.2 mg/dL (H) (8.2-11.1 mg/dL) Hgb: 11.2 g/dL (L) (14-20 g/dL)

Cl: 114mEq/L (H) (103-111 mEq/L) ALKP: 479 (H) (60-130 units/L)

Interventions : 1.)Assess respiratory rate and pattern as well as lung sounds Rationale: assessing respiratory effort and pattern will alert you to signs of worsening or improving RDS; ausculatate lung sounds to

Medications: caffeine citrate 6.2mg/dose (1 x daily) albuterol .083%, 0.13mg/dose (Q6hours) budenoside nebulizer suspension 0.5mg every 12-hours. furosemide .5mg/kg/dose (Q 12hours)

2.)Apply transcutaneous oxygen monitor or pulse oximeter. Record levels hourly. Change site of probe every 3 –4 hr. Rationale: Provides constant noninvasive monitoring of oxygen levels. 3.) Monitor fluid intake and output; weigh infant as indicated by protocol. Rationale: Dehydration impairs ability to clear airways because mucus becomes thickened. Overhydration may contribute to alveolar infiltrates/pulmonary edema.

*pt received surfactant (1.1mL) in delivery room.

Nursing Diagnosis: Impaired gas exchange r/t inadequate surfactant secondary to immature lung development AEB preterm birth, need for resuscitation and mechanical ventilation and pnueomothorax.

Assessment: pt is 25-days old; she is on SIMV mechanical ventilation; she is pink and well perfused and reactive to light, sound and touch; she has mild subcostal retractions; lung sounds are diminished but clear bilaterally; her oxygen saturation is 93% on vent; heart rate is 162 and respirations are 60/min. Her weight today is 0.88 kg and length is 35.6 cm.

Evaluation of Plan of Care : goals partially met; during my shift respirations remained between 30-60/minute and O2 sats remained above 83%. Patient still on mechanical ventilation.