Newborn Care Plan - Aspiration! HELP!

[cutieqq88]

Can someone take a look at my care plan? Thanks a million!!!

Assessment:

T = 98.4 F Axillary

HR = 128, murmur

R = 24, irregular

Pain = 0 / 6

Objective:

Birth weight: 8 lb 1oz / 3657.09grms

Length 21 inches / 53.34cm

AGA

Gestational age - 40 weeks

Capillary refill

Skin - dry, + turgor, pink

Activity - MAE

Muscle tone - flexion

Cry - lusty

Suck reflex - fair

Fontanelles - soft and flat

Respiratory / Cardiovascular - murmur

Abdomen - present active

Breastfeeding - average 5 minutes

Voiding - qs, clear, yellow

Stools - qs, transitional, meconium, green

Molding

Milia

Umbilicus - redness, swelling

Three nursing diagnosis (prioritized):

1. Risk for aspiration r/t R = 24, burp d/t immaturity of baby's internal organs.

2. Immbalanced nutrition r/t fair performanace of sucking reflex d/t insufficient intake.

3. Risk for infection r/t redness and swelling around umbilicus d/t removal of umbilicus cord.

Care Plan on Risk for Aspration:

Long Term Goal: Pt will maintain breathing pattern by discharge.

Short Term Goal 1: Pt's respiratory rate will remain between 30 to 60 by end of the shift.

Short Term Goal 2: Pt's O2 Sat. will remain > 95 by end of shift.

Nursing Intervention:

1. Nurse wil assess pt's vital sign every 4 hrs.

2. Nurse will bulb cution secretions as needed all shift.

3. Nurse will assess pt's respiratory system every 4 hrs.

4. Nurse will asses pt. O2 Sat. once every 4 hrs.

5. Nurse will burp baby as needed all shift.

ANY COMMENTS??? :)

[christieb01]

Please keep in mind that I am also a student, but I will try to give some feedback that I hope will help. I'm sure others will as well.

Three nursing diagnosis (prioritized):

1. Risk for aspiration r/t R = 24, burp d/t immaturity of baby's internal organs.

2. Immbalanced nutrition r/t fair performanace of sucking reflex d/t insufficient intake.

3. Risk for infection r/t redness and swelling around umbilicus d/t removal of umbilicus cord.

From what I remember from my OB rotation- baby's respirations are always irregular and this is actually a normal finding in a neonate- which is why we were taught to count pulse and respirations from a full minute. So my question would be- were you able to count for a full minute and the baby's respiration rate was actually 24? This would be an abnormal finding and should have been reported to the primary nurse immediately because the baby could have been having significant breathing problems.

I'm also not sure how you relate the risk of aspirations to respiratory rate and then also to burp? Was the baby not able to burp? Or was there difficulty in burping related to something? Again, I'm not sure exactly what you mean.

Your third diagnosis- risk for infection- you put r/t redness and swelling around the umbilicus- this could mean actual infection. We were taught to write a nursing diagnosis in the r/t and as evidenced by format but I'm not sure how your instructor wants you to write a diagnosis. So if it was actually a risk for infection I might put:

Risk for infection r/t cutting of umbilical cord at birth. (I would not put as evidenced by since this is a risk for diagnosis).

If it was actually infected I would write a diagnosis of:

Acute infection r/t cutting of umbilical cord at birth aeb redness and swelling around the umbilicus.

Again, I am still a student myself but I hope this helped.

[J9G2008]

For interventions, you could position the baby in a sidelying position, or elevate the HOB to alleviate possibility of aspiration. Monitor for gasping/sputtering/cyanosis during feedings. Also, an intervention for the umbilicus could be to clean the site with peroxide and water q shift.