nursing diagnosis for 3 wk old

Published

I'm doing a care plan on a 3 week old infant with severe resp distress with apnea, RSV, and risk of sepsis. The infant is also sedated. I was think of doing a nursing diagnosis on risk for imbalanced body temperature r/t inactivity or illness process but I'm not sure any feedback would be appreciated!!

Up Vote Up Vote ×
Specializes in Maternal - Child Health.

Remember Maslow and your ABC's.

With a baby who is struggling to breathe, what is your first priority?

Up Vote Up Vote ×

Jolie gives good advice. In addition, remember the ADPIE mnemonic for the steps to the nursing process. You might think about posting some assessment data before assigning a nursing diagnosis.

Up Vote Up Vote ×
Specializes in med/surg, telemetry, IV therapy, mgmt.

3 weeks old is still considered a newborn. a child up to 90 days old is considered a newborn.

  • ineffective thermoregulation r/t immature compensation for changes in environmental temperature. [see https://allnurses.com/general-nursing-student/newborn-nursing-diagnosis-346647.html for information on thermoregulation of temperature in newborns and nursing interventions.]
  • is the baby being breastfed? there are 3 diagnoses for breastfeeding.
  • what kind of cord care needs to be done. the cord stump is broken skin integrity if there is a problem there.

with regard to the baby's medical problems, it is no different than diagnosing an adult. following the nursing process to problem solve. . .start with assessment. assessment consists of:

  • a health history (review of systems) - lady partsl or c-section delivery? any problems during birth?
  • performing a physical exam - you posted no physical assessment information. nasal congestion? lung sounds? cough? audible wheezing? dyspnea? inflamed ears? chest retractions when breathing? positive sputum cultures? elevated rsv antibody titers? abnormal abgs? signs and symptoms of dehydration?
  • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - this is a baby. all basic adls have to be done for a baby--everything.
  • reviewing the pathophysiology, signs and symptoms and complications of their medical condition - this baby has rsv. you need to look up the pathophysiology of this disease as well as its signs and symptoms. you need the pathophysiology for the related factors of your nursing diagnoses. you need to see if you missed seeing the signs and symptoms of this disease in this baby. it is how you will learn to improve your assessment skills.

    [*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered they are taking - no medications or treatments mentioned. something is being done for this baby or the child wouldn't be hospitalized and nurses not needed.

from the above information you make a list of everything that is abnormal. there should be a good deal of it. nursing diagnoses are based upon abnormal data and the signs and symptoms of their medical diagnoses. you should have at least two actual respiratory nursing diagnoses here.

---------------------------------------

risk for imbalanced body temperature r/t inactivity or illness process

the r/t (risk factor) of a "risk for", or anticipated problem, must be what causes the problem.
inactivity
will not lead to fluctuations (that is what you mean by imbalanced, isn't it?) in body temperature. and what do you mean by
illness process
?
there are lots of
illness processes
. which one are you referring to? which one causes an imbalance in body temperature?

actually, i think you should just forget about using this diagnosis and concentrate on developing the respiratory diagnoses i mention above. i would diagnose
risk for infection r/t inadequate acquired immunity
to cover the risk of sepsis. 3-week olds don't have mature immune systems to fight off a septic infection, which is what happens when an infection goes from the respiratory system and goes system wide. a baby's immunity comes from what they got from their mother across the placenta and from breast milk if they are breastfeeding. an alternative, if you have symptoms of this virus (you posted none), is
ineffective protection r/t very young age aeb [evidence: signs and symptoms of the virus]

Up Vote Up Vote ×
3 weeks old is still considered a newborn. A child up to 90 days old is considered a newborn.

At the risk of distracting from the issue at hand, most sources define the newborn period (for a term baby) as the first 28 days of life (which would still include this baby). A preterm infant is a newborn until 28 days past the due date.

Up Vote Up Vote ×

Hi every body...

just i enter to say thanks for Daytonite.I am always use his guidances.

Up Vote Up Vote ×
+ Join the Discussion