Help with nursing diagnoses for a infant with respiratory distress syndrome

[skinny_mini2006]

I have an 3 week old infant born @ 32 weeks gestation and was diagnosed with respiratory distress syndrome shortly after birth. I have to come up with 3 priority nursing diagnoses and 3 interventions for each diagnosis based on the information obtain on admission to the NICU which includes: the infant was manifesting a respiratory rate of 70-breaths/ minute, expiratory grunting, nasal flaring, substernal retractions, and cyanosis in her hands and feet and around her

mouth. Her admission arterial blood gases were: pH, 7.28; Pco2, 50 mmHg; Po2, 40 mmHg; oxygen saturation, 70%; and HCO3, 20 mEq/L.

I came up with:

1. Impaired Gas Exchange r/t underdeveloped lungs and alveoli s/t prematurity amb respiratory rate of 70 breaths/minute, expiratory grunting, nasal flaring, substernal retractions, cyanosis, oxygen saturations of 70%, P02 of 40 mmHg, and PC02 of 50 mmHg.

2. Ineffective Tissue Perfusion r/t compromised blood flow s/t Respiratory Distress Syndrome amb cyanosis of hands, feet, and around mouth.

3. Risk for impaired parent-infant attachment r/t interruption of bonding process.

Any input on this would be appreciated. Thanks!!

[dscrn]

cyanotic hands, feet *acrocyanosis" immediatly following delivery is not considered abnormal---circumoral is...

[Daytonite, BSN, RN]

1. impaired gas exchange r/t underdeveloped lungs and alveoli s/t prematurity amb respiratory rate of 70 breaths/minute, expiratory grunting, nasal flaring, substernal retractions, cyanosis, oxygen saturations of 70%, p02 of 40 mmhg, and pc02 of 50 mmhg.

2. ineffective tissue perfusion r/t compromised blood flow s/t respiratory distress syndrome amb cyanosis of hands, feet, and around mouth.

when using this diagnosis the body system needs to be specified, in this case. . .

ineffective tissue perfusion, pulmonary

. the problem is that all of your symptoms of the

impaired gas exchange

are also symptoms of this diagnosis, so, in effect, you have a repeated diagnosis. they both really mean the same thing.

3. risk for impaired parent-infant attachment r/t interruption of bonding process.

newborns, particularly premies have enough actual problems. i wouldn't use an anticipated diagnosis like this unless you are required to have a psychosocial diagnosis.

a thermoregulation problem which is why they are kept in incubators. this is ineffective thermoregulation r/t immature compensation for changes in environmental temperature.

what is the skin around the umbilical cord looking like? were invasive procedures done (iv lines?). these are risk for infection.

did you evaluate imbalanced nutrition: less than body requirements r/t poor feeding behavior?