NCP PROPER
Problem: Difficulty of Breathing
• Objective Data:
V/S of: CR= 128 bpm T= 36.0 degrees Celsius
RR= 58 cpm
Prematurity at 33 weeks AOG
Weighs 1.08 kg
With O2 supplement regulated at 0.5 LPM via nasal cannula
With Hgt result of 20
With irregular respirations
Acrocyanotic
With APGAR scoring of 6,7
cool to touch
weak cry noted
• Goal: After 3 days of nursing interventions, the patient will reduce risks
for potential complications.
Objectives:
After 8 hours of nursing interventions, the patient will be warm to
touch.
After 8 hours of nursing interventions, the patient will have normal and
regular respirations.
After 8 hours of nursing interventions, the patient will be free of signs
of respiratory distress.
After 2 hours of nursing interventions, the parent will demonstrate
ability for proper infant care.
• Explanation of the Problem
Any infant born prior to completing 37 weeks’ gestation is identified as
premature. Thus, the level of development and maturity, and often the
degree of complications, varies within this group, dependent on the length of
gestation. Pre-term birth can lead to infants with under-developed lungs.
These lungs show incomplete development of the alveolar type II cells, cells
that produce surfactant. The lungs of pre-term infants may not function well
because the lack of surfactant leads to increased surface tension within the
alveoli. Thus, many alveoli collapse such that no gas exchange can occur
within some or most regions of an infant's lungs
• NCP Proper
1. Problem #1: Impaired gas exchange related to inadequate surfactant
levels
Interventions Rationale Criteria Evaluatio
for n
Evaluatio
n
Dx:
1. Review 1. Prolonged labor increases
information risk for hypoxia. In
related to addition, infants with low
infant’s Apgar scores and who
condition such required resuscitative
as type of measures at birth, may
delivery, APGAR require more intense
score and need interventions to stabilize
for resuscitative blood gases and may
methods after have
delivery. suffered CNS injury with
damage to the
hypothalamus, which
2. Note gestational controls respiratory
age, weight, functioning.
and sex.
2. Neonates born before 30
weeks’ gestation and/or
weighing less than 1500 g
are at higher risk for
developing RDS. Note:
The majority of deaths
3. Assess related to RDS occur in
respiratory infants weighing less than
status, 1500 g.
assessing signs
of respiratory
distress. ((e.g.,
tachypnea,
nasal flaring, 3. Tachypnea indicates
grunting, respiratory distress,
retractions, especially when
rhonchi, or respirations are >75/min
crackles) after the first 5 hr of life.
Expiratory grunting
represents an attempt to
maintain alveolar
expansion; nasal flaring
is a compensatory
mechanism to increase
diameter of nares and
increase oxygen intake.
Crackles/rhonchi
may indicate pulmonary
vasocongestion
associated
with PDA, hypoxemia,
acidemia, or immaturity
ofmuscles in arterioles,
which fail to constrict in
response to increased
oxygen levels.
4. Monitor fluid
intake and
output; weigh
infant.
4. Dehydration impairs
ability to clear airways
because mucus becomes
thickened. Overhydration
may contribute to alveolar
infiltrates/pulmonary
edema. Weight loss and
increased urine output
may
indicate diuretic phase of
RDS
5. Observe for
evidence and
location of 5. Cyanosis is a late sign of
cyanosis. low PaO2 and does not
appear until there are
slightly more than 3 g/dl
of reduced Hb in central
arterial blood, or 4–6 g/dl
in capillary blood, or until
oxygen saturation is only
75%–85%, with PO2 levels
of 32–41 mm Hg.
Therefore, prompt
intervention is crucial.
6. Monitor HGT
levels.
Tx: 6. Low blood glucose or
hypoglycemia may cause
metabolic problems in the
infant and may manifest
in varied signs and
symptoms including
7. Apply breathing problems.
transcutaneous
oxygen monitor
or pulse
oximeter. 7. Provides constant non
Record levels invasive monitoring of
hourly. Change oxygen levels. Note:
site of probe Pulmonary insufficiency
every 3–4 hr. usually worsens during
the first 24–48 hr, then
reaches a plateau.
8. Maintain 8. Cold stress increases
temperature infant’s oxygen
within normal consumption, may
range. promote acidosis, and
may further impair
9. Promote rest; surfactant production.
minimize 9. Reduces metabolic rate
stimulation and and oxygen consumption.
energy
expenditure. 10. Prone position
compensates for weak
10. Position infant chest and abdominal
on abdomen if muscles, decreasing the
possible. amount of respiratory
11. Administer effort required to expand
supplemental chest, thus allowing
oxygen, as optimal chest expansion
needed and enhancing inhalation
of air. Stimulates
respirations and
ventricular growth.
Positioning infant on
abdomen or
side reduces risk of
aspiration of
mucus/regurgitated
Edx: formula.
11. Hypoxemia and acidemia
may further decrease
surfactant production,
increase pulmonary
vascular resistance and
vasoconstriction, and
cause ductus arteriosus
to remain open.
Immaturity of the
hypothalamus may
necessitate ventilatory
assistance to maintain
respirations.
Reference:
[Link]
NANDA, 11TH edition, Marilynn Doenges
Focus on Pathophysiology, Barbara Bullock
Principles of Anatomy and Physiology, Tortora
Fundamentals of Nursing, Kozier
