Nursing DX for 23 weeker.

[Bortaz, MSN, RN]

Baby, 23 weeks gestational age, delivered SVD due to broken bag of water, 16 year old mother. On Jet Vent, weighs 716 grams, blood glucose 211, ordered minimum stimulation.

What are a few nursing dx's appropriate to this case? I keep coming up with a "risk for" dx's, but am trying to avoid over-using the same old "risk for impaired tissue perfusion blah blah" that is so easy to apply to nearly every case.

Any suggestions appreciated! More case info available on request.

[SuesquatchRN, BSN, RN]

Well, 23 weeks those aren't risks.

Impaired gas x/c r/t inadequate lung development

Ineffective thermal regulation r/t too little fat

Impaired nutrition - LT body requirements r/t weak sucking

EVERYTHING is a real problem.

[Daytonite, BSN, RN]

remember that diagnosing is always based on abnormal assessment data and the evidence that is collected. one of the analogies i use to explain the nursing process and diagnosing is to compare it to police detection work (you have got to appreciate this!) when the police are trying to solve a crime, they already have their diagnosis (the crime). what they are engaged in is finding evidence (abnormal assessment data) to prove, or support, the crime. so they start investigating. now, i don't know the exact methods that the police are taught, but i think i'm pretty safe in saying that they are just not told to go out and see what they can learn. there are probably some methods and processes they are taught to follow. we nurses are taught to find the evidence and put it together to determine what the problems are. we use the nursing process to do that. in successive lectures and classes the steps of this process are expanded upon for you.

a premie, and i'm not being mean, is not normal compared to a 40-week full gestation infant in oh-so-many ways. and those different ways become abnormal assessment data by virtue of the fact that they just do not fit the "normal" picture of a newborn. it's nothing personal. but it is going to help logically point you to the problems this little one has. if you have a list of what the assessment of normal newborn should be, compare this little one against it. these children tend to have immature respiratory organs, immature kidneys, problems with their eyes and skin and need to be watched for hemorrhage.

respiratory distress syndrome is the most common problem seen in premies and this baby needs to be monitored for

• tachypnea
  
• tachycardia
  
• nasal flaring
  
• retractions
  
• cyanosis
  
• grunting upon expiration
  
• rales
  
• decreased breath sounds
  
• acidosis

you might want to address some of the complications of ventilator therapy (oxygen toxicity, fluid volume excess, infection, decreased cardiac output). https://allnurses.com/forums/1832873-post14.html

thermoregulation is a problem with all newborns and there was a recent thread about this including everything you need for this diagnosis including weblinks to information about the nursing interventions: https://allnurses.com/forums/f50/newborn-nursing-diagnosis-346647.html

because of their immature kidneys they are prone to fluid and electrolyte imbalances. they can lose fluid through their skin if they are being kept under radiant warmers or receiving phototherapy. they need to be monitored for dehydration and overhydration. they should have a urine output of more than 2 ml/kg/hour. their skin and mucus membranes need to be watched for dryness, the turgor noted, fontanels noted for any sunkenness and electrolytes monitored.

their skin is fragile and they are born with more vernix caseosa and lanugo than full term babies. their skin damages much easier, so it must be assessed regularly for breaks and handled with special precautions. no adhesives or irritating chemicals. special lotions are used on the skin to reduce the water loss mentioned above. and, bathing is done extremely carefully. these babies can get bed sores, so their positioning and moving is crucial.

has the baby been poked and prodded for any invasive procedures? babies do experience pain and there are interventions for it. they also experience the stress of the noise and lights and show physical signs of it (increased pulse and respirations, decreased sats, extending arms, fisting or splaying of fingers, worried expression, avoiding eye contact, hiccoughing, regurgitating, fatigue, coughing and yawning).

and, then there is the possibility of delayed bonding with parents because of all the procedures being done to keep the baby alive. is the mother showing any kind of interest in the baby? the elevated blood sugar most likely comes from this mother and her medical problem (diabetes? alcohol intoxication?).

[Bortaz, MSN, RN]

That's awesome, and truly appreciated!