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290 MATERNAL-INFANT NURSING CARE PLANS preterm birth L immunity t invasive procedures Sepsis Neonatorum chorioamnionitis blood borne pathogens vaginal, GI organisms Immature Immunological System + Exposure I I I + + Prenatal Intrapartum congenital PTL $. malformations pretem ROM 4-ascending I pathogens-1 * Neonatal I 1 nosocomial pathogens invasive procedures t nosdcomial exposure NEONATAL 4 SEPSIS meningitis DIC antibiotics I\ “1 thrush superinfection resolution | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 29 1 Human immunodeficiency virus, type 1 (HIV-1) is the causative organism for AIDS (acquired immunodeficiency syndrome). The HIV retro- virus replicates in the nucleus of T-4 helper lym- phocytes (identified by the CD4 surface antigen), causing premature death of those cells. This results in a profound depression of cell-mediated immu- nity in the host. The body is eventually over- whelmed by opportunistic infections. The virus is transmitted by direct contact with infected blood or body fluids. There are three perinatal modes of transmission for HIV. The fetus may be infected across the pla- centa during pregnancy, the neonate may acquire the virus during birth from exposure to maternal blood and body fluids, or HIV virus in the breast milk may infect the infant. The infant infected in utero has a poor prognosis. One goal of nursing care is to prevent the last two modes of transmis- sion. Newborns of HIV positive mothers will also test positive at birth due to the HW antibodies received passively from the mother during the last few weeks of pregnancy. Approximately one third of these infants will actually be infected with the virus. Additional testing is needed to determine which infants have acquired the virus and which have not. The polymerase chain reaction and HIV culture tests may provide a diagnosis as early as 4 to 6 months of age while maternal antibodies are still present for 15 to 18 months (basis of ELISA and Western Blot tests). Most infants will be asymptomatic at birth. Signs and Symptoms enlargement of liver and spleen swollen lymph glands failure to thrive, poor feeding, diarrhea rash, cough, signs of pneumonia (Pneumocystis neurological or developmental deficits carinii, interstitial pneumonitis) Medical Care Maternal antiviral drug: zidovudine (AZT) dur- ing the last two trimesters of pregnancy and during labor and delivery Avoidance of an episiotomy or other actions creating excess bleeding during birth, careful suctioning of infant at birth, bathing of infant before any injections or invasive procedures, formula feeding Laboratory testing: urine screening, baseline immunological tests HIV infection Frequent pediatric follow-up visits; testing for Prophylactic drugs: infant is started on zidovu- dine, trimethoprim-sulfamethoxazole (to pre- vent pneumocystis carinii pneumonia), and monthly doses of gamma globulin IV while diagnostic tests are being done Nursing Care Plans FZuid k Zume Deficit, Risk for (282) Related to: Decreased intake secondary to poor feeding. Increased fluid loss secondary to loose stools/diarrhea. possible craniofacid malformations if congenital infection | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
232 ~TE~~-INF~T NURSING CARE PLANS Adtlitlonal Diagnoses and Plans Related to: Immature immunological system. Possible exposure to maternal infected blood and body fluids (HIV, Hepatitis B). Possible immune suppression secondary to transplacental HIV infection. ~e~n~n~ Characteristics: None, since this is a potential diagnosis. Goal: Infant will not experience neonatal infection by (datehime to evaluate). Outcome Criteria Infant receives prophylaxis (specie: e. g., gamma globulin), Infant appears free of opportunistic infection: temperature is stable between 36. 5 and 37°C (97. 7-98. 6"F), no respiratory distress, abdomen is soft and nondistended without hepatosplenomegaly. INTERS%NTIONS RATIONALES Suction infant well at birth with bulb syringe or wall suction device. Do not use mouth suction devices. Provide routine newborn care: dry inht well to remove all blood and body Buids. Delay eye prophylaxis, injections or other invasive procedures until afier the first bath. Bathe infkt thoroughly as soon as possible after ini- tial assessment. Return to warmer until temperature is stabilized. Use Standard Precautions (formerly Universal Precautions) when caring for ail clients. Wear gloves, gowns, and eye shields as needed to prevent expo- sure to blood or body flu- ids. Dispose of potentially infectious items (diapers, wipes, etc. ) per agency pol- icy (specifj. : e. g., hazardous waste containers, red bags, etc. ). Identify mothers at risk as well as those with con- firmed HIV or hepatitis B infection. Avoid invasive procedures during labor and birth (e. g., fetal scalp electrode, IUPC, episioto- my, or operative delivery). Standard Precautions are implemented to avoid caregiver exposure to blood-borne pathogens such as HN or hepatitis 3 viruses. Risk factors may include IV drug abuse, multiple sexual partners, history of multiple STD's, or blood transfusion before 1985. Invasive procedures during labor may infect the fetus. Wash skin with soap and water before injections or heel sticks. Label all specimens and notify lab of infant's HIV exposure per protocol. Monitor lab results. Monitor infant for signs of opportunistic infection: temperature instability, res- piratory distress, abdomi- nal distension, hepatosplenomegdy, eniarged lymph glands, activity, seizures, jaundice, petechiae, skin lesions, Candidiasis (thrush), or chorioretinitis. Suctioning removes infecc- ed maternal secretions, Mouth suction devices cre- ate risk of exposure for caregiver. The infant requires the same care as any newborn: ther~ore~~tion, etc. Drying the infant carefully helps remove maternal blood and body fluid from the infant's skin. Delay helps avoid trans- mission of the virus from the infant's skin into the body, Early and thorough bathing removes maternal blood and body fluids from infant's skin. Infants bathed soon afier birth regain temperature stabifi- ty as well as those bathed tater. Additional washing helps prevent exposure from skin during invasive procedures. Interventions help prevent exposure of laboratory per- sonnel to potentially infected specimens. Monitoring provides infor- mation about early signs and symptoms of oppor- tunistic infection. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 293 INTERVENTIONS RATIONALES Isolate infant if indicated by presence of infection (specify: e. g., CMV, enteric infection, etc. ). Administer prophylactic medications as ordered (specify e. g. immune glob- ulin for infants of hepatitis B infected mothers). Teach mother to wash her hands before caring for infant and to avoid expos- ing the infant to visitors with infections. Teach mother that she will need to bottle feed her baby. Provide assistance as needed. Teach family about HIV testing and prophylactic medications that will be provided for the infant. Instruct family in Standard Precautions to use when caring for infant (specify: e. g., wash hands before and after care, avoid con- tact with wet diapers, etc). Verify understanding. Make appointments for follow-up care before dis- charge. Instruct family to monitor the infant for signs of infection and to call the caregiver. Provide phone numbers. Isolation prevents trans- mission of infection to other infants in the nurs- ery- (Specify action of prophy- lactic medication. ) Washing hands helps pre- vent transmission of the virus from the mother to the infant. The infant may already be HIV infected and immune suppressed at birth. HIV may be transmitted through breast milk. Instruction helps the mother provide optimum nutrition for her baby. Instruction ensures that family understands the delay in diagnosing whether the infant is infected or not and those medications will be given until then. Standard Precautions help prevent transmission of the virus from the infant to family members. Routine infant care using standard precautions is unlikely to cause infection. Making appointments ensures follow-up care. The infant will need to be seen more frequently. Information and phone numbers help the family to provide care for the infant. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Did infant receive appropriate prophylaxis? Specify drug, dose, route, and time. Is infant free of signs of infection? Describe temperature ranges, respiratory and abdominal status. ) (Revisions to care plan? D/C care plan? Continue care plan?) Nutrition, Altered: Less Than Body Requirements, Risk for Related to: Feeding intolerance secondary to infectious processes. Inadequate absorption of nutrients secondary to diarrhea. Defining Characteristics: None, since this is a potential diagnosis. Goal: Infant will obtain adequate nutrition for body requirements by (date/time to evaluate). Outcome Criteria Infant will lose no more than 10% of birth weight (specify for infant). Infant will ingest adequate formula to meet body needs (specify calories and ounces of formula needed each day). INTERVENTIONS RATIONALES Weigh infant at birth and each day without diaper or clothing. Cover scale with blanket and zero before weighing. Protect from falls without touching infant. Compare to previ- ous weights. Assess infant's suck reflex during initial assessment. Inspect oral cavity for signs Daily weights provide information about infant's weight loss or gain. Assessment provides infor- mation about infant reflex needed for successful feed- | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
294 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES of thrush (white patches) and notify caregiver. Administer medications as ordered (specify: e. g., Nystatin for thrush). Assess infant for first stool and urine. Obtain speci- mens as needed. Label and notify lab of possible HIV status per agency protocol. Monitor all intake and output (weigh diapers, 1 gm = 1 cc). Provide sterile water for infant as ordered. Assess for swallowing, excessive gagging, choking, or vom- iting and notify caregiver. If infant tolerated water feeding, assist mother to provide first formula feed- ing (specify formula type: e. g., 24 calorie and amount) as ordered. Monitor infant for signs of feeding intolerance: exces- sive spitting up, abdominal distention, test abnormal stools for occult blood. Notify caregiver. Administer gavage feedings or TPN as ordered (speci- fy). Check for residual before gavage feedings. ing. The HIV positive infant is at risk for oppor- tunistic infection such as thrush. (Specify action of drugs that are ordered. ) First stool and urine indi- cate normal GI and renal function. Specimens may be needed for lab tests. Lab personnel are alerted to potentially infected specimens. Monitoring provides infor- mation about fluid balance and adequate caloric intake. Sterile water allows assess- ment of infant's feeding ability with less risk for injury from aspiration than if formula were provided first. Intervention promotes maternal-infant attach- ment and bonding. Infant is at risk for failure to thrive and may be started on high-calorie formula. Feeding intolerance may indicate presence of gas- trointestinal infection. Gavage or TPN feedings provide optimal intake if the infant cannot tolerate oral feedings. Residual may indicate intolerance of gav- age feedings. 1"IERVENTIONS RATIONALES Provide teaching to family as needed: hold infant close with head higher than stomach (do not prop the bottle); ensure nipple is full of formula; burp infant after each ounce or more frequently, and when finished; place infant on right side after eating. Teach parents that a small amount of regurgitated formula is normal after eating but to notify care- giver if infant vomits the whole feeding. Inform mother of the schedule suggested by her caregiver (specifjr-may be frequent small feedings) and ensure that sterile for- mula is available for feed- ings. Praise parents for success- ful feeding of their new baby. Teach parents about the normal newborn's stools: meconium, transitional, and milk stools: color, consistency, smell, and fre- quency. Instruct them to notify caregiver for diar- rhea or abnormal stools. Teach parents that weight loss of up to 10% is nor- mal after birth but then their baby should gain about an ounce per day after that for the first 6 months. Provide written and verbal instructions on infant Teaching promotes effec- tive infant feeding and enhances family bonding with infant. Teaching provides infor- mation the parents need to differentiate normal spit- ting up from vomiting that may signal GI infection. Information helps the mother feed her baby effectively. Sterile formula for each feeding helps pre- vent gastrointestinal infec- tion. Praise promotes effective parenting. Teaching provides infor- mation the parents need to distinguish normal new- born bowel movements from signs of infection or diarrhea. Teaching provides infor- mation that may allay par- ents' fears about normal neonatal weight loss. Written and verbal infor- mation provide reinforce- | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 295 INTEKVENTIONS RATIONALES feeding (and formula preparation) at discharge per infant's caregiver. discharged. ment of caregiver's instruc- tions after family has been (specify for infant). Infant will ingest adequate formula to meet body needs (specify calories and ounces of formula needed each day). Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (What is infant's weight? What is percent of weight loss? Specify infant's caloric intake. Is this adequate?) (Revisions to care plan? D/C care plan? Continue care plan?) Parenting, Altered Related to: Family at risk for developing parenting difficulties secondary to maternal terminal illness with a potential that infant has a terminal illness. Lack of knowledge, social isolation, and history of risk-taking behavior. Defining Characteristics: Lack of parental attach- ment behaviors (specify: e. g., avoids eye contact with infant, doesn't talk to baby or explore with fingers). Parents avoid holding or caring for infant, make disparaging remarks about baby (specify with quotes). Goal: Infant will experience appropriate parenting by (date/time to evaluate). Outcome Criteria INTERVENTIONS RATIONALES Review prenatal and labor records for information about maternal attitude towards pregnancy and birth of infant. Establish rapport and demonstrate respect for parents by providing priva- cy and dedicated time to d' iscuss concerns. Observe parent-infant bonding and attachment behaviors. Observe par- ents' care-taking activities. Provide feedback to par- ents about observations. Encourage parents to iden- tify and explore fears and concerns about parenting the infant now and in the future. Assess parents' understand- ing of infant's condition and provide accurate infor- mation about the condi- tion, treatment, and prog- nosis (specify: e. g., for HIV, hepatitis B, narcotic addiction, etc. ). Provide information about infant's need for a safe nur- turing environment to pro- mote optimum growth and development. Assist family to evaluate social and financial sup- port systems. Discuss resources that may be available to the family. Review provides informa- tion about parenting risk behavior that was identi- fied earlier. Providing a safe and non- judgmental environment assists the parents to feel comfortable discussing sensitive concerns. Observation provides information about the presence of expected par- enting behaviors. Feedback gives the parents informa- tion they may be unaware of (e. g., that they avoid looking at the baby, etc. ) Encouragement helps the parents to begin to identify fears and concerns. Identification is necessary in order to plan coping strategies. Accurate information decreases unsubstantiated fears and provides antici- patory guidance ro parents. Parenting is a learned skill. Information helps parents to provide for infant's growth and development needs. The family may feel social- ly isolated, family mem- bers may avoid the infant, financial concerns may cause increased stress. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
296 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES ~ Resources may help ease the financial burden and social isolation of parents. Planning to provide for their infant's needs is part of effective parenting. Intervention empowers parents to make needed changes in lifestyle or ded- sions about infant care. Referrals provide addition- al resources for the parents Help parents to make a plan for provision of appropriate care for their baby (specify: e. g., may include drug-treatment program for parents, foster care for baby, etc. ). Initiate referrals as indicat- ed (specify: e. g., social ser- vices, community and infant. resources, early-interven- tion programs, 12-step programs, counseling, etc. ). Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (Did parents discuss fears and risk of developing parenting problems? Describe parents' behaviors toward infant (e. g., eye contact, holding, talking to, and feeding the baby). Are they appropriate?) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 297 HIIVAIDS perinatal exposure maternal HIV/AIDS $. transplacental intrapartum breast milk 1 transmission of HIV retrovirus to fetus/neonate nucleus of helper T-lymphocyte (CD4 surface antigen) 4- replication of HIV destruction of T lymphocyte-release of HIV from cell 1 4 helper T-lymphocytes 1 & monocyte-macrophage response immune suppression opportunistic infections parotitis chronic candidiasis (thrush) Pneumocystis carinii pneumonia lymphoid interstitial pneumonitis (LIP) progressive neurologic disease failure to thrive chronic diarrhea lymphadenopathy hepatosplenomegaly | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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NEWBORN 299 Infant of Substance Abusing Mother Infants of mothers who use alcohol and/or illicit drugs during pregnancy are at risk for congenital defects, pregnancy complications, passive addic- tion, or a combination of these problems. Social or recreational alcohol and drug use is relatively common in women of childbearing age in the United States. Frequently the mother will use sev- eral substances including tobacco. Fear of reprisal may prevent the pregnant woman from seeking help or admitting substance abuse to caregivers. Signs & Symmoms pregnancy complications: placental abruption, IUGR, fetal distress, meconium aspiration SGA, LBW, or preterm infant usually without RDS congenital defects: craniofacial anomalies, heart, brain defects abnormal muscle tone: rigidity, arching, or hypotonia, lethargy irritable, difficult to console, shrill cry, sleep dis- turbances tremors, sneezing, yawning, seizures uncoordinated Suc Wswallow reflex, poor feed- ing, vomiting, diarrhea disorganized response to stimulation Heroin is replaced with methadone during pregnancy. Dose is gradually reduced but not discontinued to avoid fetal withdrawal Narcotic antagonists or agonisdantagonist drugs are avoided for mom/baby to prevent sudden narcotic withdrawal (e. g., Narcan, Stadol, Nubain) Toxicology screen of mother and infant to iden- Positive drug screen for infant is reported to ti@ substances DCFS Labs: CBC, electrolytes, glucose monitoring, urine specific gravity, cultures as indicated decreasing doses formula Sedation: Phenobarbital, paregoric, diazepam in 0 Decrease environmental stimulation, 9 calorie Nursing Diagnoses Infiction, Risk for (292) Related to: Maternal risk behaviors. Fluid filurne Deficit, Risk for (282) Related to: Insufficient intake secondary to poor suck and swallow. Excessive losses secondary to diarrhea. Parenting, Altered (295) Related to: Family at risk for ineffective parenting secondary to history of risk-taking behaviors and ineffective coping with stress. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
300 MATERNALINFANT NURSING CARE PLANS Additional Diagnoses and Plans Infant Feeding Pattern, Ineflective Related to: Muscle weakness/hypotonia secondary to neurological impairment, maternal substance use, congenital defects, or lack of maternal skill (specify). Defining Characteristics: Infant is unable to initi- ate or sustain an effective suck; unable to coordi- nate suck, swallow, and breathing. Infant vomits most of feedings (specify). Infant is unable to obtain adequate calories (specify intake/calories and calorie needs for this infant). Goal: Infant will obtain needed nutrition by the INTERVENTIONS RATIONALS Assess the mother's skill in feeding infant and infant's feeding pattern: suck, swal- low, and coordination of swallowing with breathing. Assess caloric intake com- pared with needs (specify). Monitor intake and out- put. Support mother's attempts to feed baby and provide teaching as needed: pro- mote a quiet, calm envi- ronment, upright position- ing of infant, use of root- ing reflex, support of infant's chin as needed. Offer praise for mother's attempts to feed her baby. Explain motor develop- ment delays and interven- tions to improve infant's feeding pattern. Assessment provides infor- mation about the potential cause of ineffective feeding patterns. Assessment provides infor- mation about fluid balance and infant's additional caloric needs. Support and teaching assist the mother to feed her baby and promote mater- nal role attainment. The mother may be unsure of her skills and feel inadequate if the infant is a poor feeder. Support and explanation help the mother to under- stand the infant's needs. INTERVENTIONS RATIONALES Supplement oral feeding with gastric feeding to ensure caloric intake as ordered (specify formula type, moundday: e. g., 1501250 kcallkglday may be ordered). Encourage mother to hold and cuddle infant during gastric feedings (e. g., kan- garoo care). Provide for non-nutritive sucking (pacifier, hands). Consult with occupational therapist as needed for interventions to improve oral muscle development and coordination. The infant needs adequate calories for growth and development of skills needed to obtain nutrients orally. Kangaroo care during gas- tric feeding promotes maternal-infant attach- ment and bonding and calms infant to promote digestion. Non-nutritive sucking pro- vides exercise to muscles needed for an effective feeding pattern. Consult provides early interventions to promote optimum oral motor development. oral route by (datehime to evaluate). Outcome Criteria Infant ingests (specify ounces of formula/breast milk per feeding/day). Infant gains appropriate weight (specify). Infant shows increasing skill in oral feedings (specify for baby: e. g., obtains '/p of calories orally, etc. ). Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Specify infant's intake. Specify infant's weight and gain. Describe infant's skill in oral feedings: e. g., | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 30 1 Defining Characteristics: Infant is irritable, rest- less, and hyper-responsive to stimulation. Sleep pattern is short and easily interrupted (specify: e. g., sleeps lightly for 20 minutes and wakes with a shrill cry). Goal: Infant will experience an improved sleep pattern by (datehime to evaluate). Outcome Criteria Infant will sleep for (specify hours: e. g., 12-14 hours a day) without use of or gradual withdrawal of sedative medications. INTERVENTIONS RATIONALES Assess infant's sleep/wake pattern and response to environmental stimuli. Observe for signs of nar- cotic withdrawal: hyperac- tivity and irritability, mus- cle rigidity, shrill cry, sneezing, yawning. Notify caregiver. Decrease environmental noise and light: cover iso- lette with blanket, dim nursery lights at night, move noisy equipment, avoid talking around infant's bed. Teach mother about her infant's sleep pattern dis- turbance and interventions to promote rest. Wrap infant snugly and provide repetitive motion: rocking, walking, or pat- ting back. Play soft music or womb sounds and note infant's Assessment provides infor- mation about infant's cur- rent patterns and responses to stimulation. Infants experiencing with- drawal may need sedative medications to promote adequate rest during acute phase. Interventions decrease environmental stimulation and infant's hyperactive responses. Share information and support mother's caretak- ing activities. Wrapping, holding, and repetitive movements pro- vide comfort, security, and promote behavioral organi- zation. Soft sounds may be com- forting to infant or may be INTERVENTIONS RATIONALES response. Provide for non-nutritive sucking by using a pacifier or keeping hands free. distracting. Pacifier or hand sucking provides comfort and pro- motes rest for infant. Avoid waking infant for nonessential care activities. Cluster care while awake. Teach breast-feeding mother to avoid caffeine, chocolate, gas-producing foods (e. g., cabbage) and highly spiced foods for a week. Foods may then be added one at a time and infant's response observed. Administer sedatives as ordered (speci Fy: drug, route, time). Assist caregiv- er in decreasing dosage according to infant's responses. Interventions promote infant sleep periods. Most nursing care can be done during wakeful periods. The specified foods have been reported by some breast-feeding mothers to cause GI upset in their babies. (Specify action of particu- lar drug. ) Drugs interfere with REM and deep sleep stages and should be dis- continued as soon as possible. Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (Specify how long infant is sleeping. Specify dosage of sedative if being used and if dose has been decreased. ) (Revisions to care plan? D/C care plan? Continue care plan?) Infant Behavior, Disorganized Related to: Altered CNS response secondary to prenatal exposure to drugs/alcohol. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
302 MATERNALINFANT NURSING CARE PLANS Defining Characteristics: Specify (e. g., irritability, tremors, seizures, tachycardia, tachypnea, apnea, sneezing, gagging, yawning, hypotonia, lethargy, shrill cry, difficult to console, etc. ). Goal: Infant will demonstrate increase in behav- ioral organization by (datehime to evaluate). Outcome Criteria Infant demonstrates periods of calm, quiet alert state. Infant shows less motor instability (specify: e. g., tremors, rigidity, etc. ). Holding can console infant, rocking, talking. INTERVENTIONS RATIONALES Assess infant's behavioral responses to stimuli. Observe care-taking skills and emotional responses of parents. Assist parents to identify behavioral cues of infant. Discuss infant's disorga- nized behavior with par- ents. Involve them in plan- ning and implementing interventions to assist the baby. Handle infant slowly and calmly. Maintain flexion when handling baby. Swaddle securely with hands free for sucking. Position in crib prone or on side with blanket rolls creating a nest. Decrease environmental stimulation as much as possible: cover isolette with a blanket, dim lights, decrease noise. Alert others Assessment provides infor- mation about individual infant's responses to partic- ular stimuli. Parents who are substance abusers may also be at risk for neglect or abuse of their children. Assisting parents to under- stand their infant pro- motes parent-infant attach- ment and facilitates effec- tive parenting of the diffi- cult infant. Interventions provide external regulation of motor control promoting comfort and rest. Excessive stimulation leads to increased behavioral dis- organization and expendi- ture of energy needed for growth and development. INTERVENTIONS RATIONALES to infant's needs by placing sign on isolette. Maintain a calm routine for infant care. Cluster activity and avoid over- stimulation or interruption of sleep. Teach parents to provide kangaroo care holding infant securely in flexed position against skin of chest. Assess infant's response. Gradually provide develop- mental stimulation (touch, talking, music, etc. ) noting infanti response and increasing or decreasing stimulation based on infant's cues. Teach parents about growth and development milestones for infancy. Provide written materials if appropriate. Teach parents to maintain a consistent routine for baby after discharge. Suggest trying an infant swing for baby. Initiate home follow-up visit for infant. Provide phone number for parents to call with concerns. Refer parents as indicated (specify: e. g., early inter- vention programs, social service, counseling, etc. ). Providing a consistent rou- tine with clustered activity assists the infant to orga- nize behavior. Kangaroo care may help calm the infant, or may be too stressful at first. Care is based on infant's response. Developmental stimulation supports infant's growing abilities based on individ- ual response. Anticipatory guidance helps parents to provide appropriate care for their baby. The infant benefits from routine by developing pat- terns of organized behav- ior. Repetitive motion is calming for some infants. Home visits provide infor- mation on infant's progress and parents' care-taking abilities. The infant may be at risk for neglect or abuse if parents become frustrated with caring for a difficult baby. Referrals are initiated to provide continual support and surveillance. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NEWBORN 303 Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Does infant exhibit periods of quiet alert state? Describe changes in motor excitability. How is infant consoled? Has this improved?) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
304 MATERNALINFANT NURSING CARE PLANS Infant of Substance Abusing Mother Maternal Prenatal Substance Abuse Congenital Defects FAS craniofacial malformations congenital heart or brain defects microencephaly 1 Birth 1 withdrawal Pregnancy Complications PIH abruptio placentae placenta previa asphyxia preterm LBW CNS GI Respiratory tremor uncoordinated, weak ? risk for meconium Shrill cry suck and swallow aspiration initability, restlessness vomiting tachypnea lethargy loose stools apnea sleep disturbance diarrhea t secretions yawning, sneezing dehydration hypertonus/ hypotonus t reflexes difficult to console Long-Term Problems mental retardation behavior disorders hyperactivity ? incidence of neglect/abuse ? incidence of SIDS | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
REFERENCES 305 | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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REFERENCES 307 References Bobak, I. M., and Jensen, M. D. Maternity and Gynecologic Care: The Nurse and the Family, 5th Ed. St. Louis, MO: Mosby-Year Book, 1993. Carpenito, L. J. Nursing Diagnosis: Application to Clinical Practice, 7th Ed. Philadelphia, PA: J. B. Lippincott, 1997. Cunningham, G. F., et al. Williams Obstetrics, 19th Ed. Norwalk, CT: Appleton & Lange, 1993. Doenges, M. E., and Moorhouse, M. F. Maternal/Newborn Plans of Care: Gui&linesfor Planning und Documenting Client Care, 2nd Ed. Philadelphia, PA F. A. Davis, 1994. Fischbach, F. T. A Manual of Laboratory and Diagnostic Tests, 5th Ed. Philadelphia, PA J. B. Lippincott, 1995. Jaffe, M. Pediatric Nursing Care Pkzns. Englewood, CO: Skidmore-Roth Publishing, 1998. Masten, Y. The Skidmore-Roth Outline Series: Obstetric Nursing, 2nd Ed. Englewood, CO: Skidmore-Roth Publishing, Inc., 1997. Mc Cance, K. L., et al. Patbopbysiology: The Biologic Barisfor Diseare in Adults and Cbikdren, St. Louis, MO, Mosby-Yearbook, 1997. Murray, M. L. Antepartal and Intrapartal Fetal Monitoring, 2nd Ed. Albuquerque, NM: Learning Resources International, 1997. Murray, M. Essentials of Electronic Fetal Monitoring: Antepartal and Intvapartul Fetal Monitoring, NAACOG Educational Resource, 1989. Nichols, F. H., and Zwelling E. Maternal-Newborn Nursing: Theory and Practice Philadelphia, PA: W. B. Saunders. 1997. Rudolph, A. M., et al., eds. Rudolphi Pediatrics, 20th Ed. Stamford, CT: Appleton & Lange, 1996. Wilson, B. A., et al. Nurse: Drug &ide 1996, Stamford, CT: Appleton & Lange, 1996. Wong, D. L. Wbulq, Q Wongi Nursing Care of Infnts and Childven, 5th Ed. St. Louis, MO: Mosby- Yearbook, 1995. Periodicals Cosner, K. R., and de Jong, E. “Physiologic Second-Stage Labor. ” MCN 18 (Jan/Feb): 38-43, 1993. Drake, l? “Addressing Developmental Needs of Pregnant Adolescents. ” JOGNN 25(6): 518-524, 1996. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
308 MATERNAL-INFANT NURSING CARE PLANS Findlay, R. D., et al. “Surfactant Therapy for Meconium Aspiration Syndrome. ” Pediatrics 90( 1): 48-52, 1996. Gebauer, C. L., and Lowe, N. K. “The Biophysical Profile: Antepartal Assessment of Fetal Well-Being. ” JOGNN 22(2): 1 15-124, 1993. Giotta, M. I? “Nutrition During Pregnancy: Reducing Obstetric Risk” Journal of Perinatal and Neonatal Nursing 6(4): 1-12, 1993. Griffin, T., et al. “Parental Evaluation of a Tour of the Neonatal Intensive Care Unit During a High-Risk Pregnancy. ” JOG” 26(1): 59-65, 1997. Hutti, M. H. “A Quick Reference Table of Interventions to Assist Families to Cope with Pregnancy Loss or Neonatal Death” Birth l S(1): 33-35, 1988. Keleher, K. C. “Occupational Health: How Work Environments Can Affect Reproductive Capacity and Outcome. ” Nurse Practitioner. 16(1): 23-33, 1991. Lewis, C. T., et al. “Prenatal Care in the United States, 1980-94. ” Vital Health Stat 21(54), National Center for Health Statistics, 1996. Lowe, N. K., and Reiss, R. “Parturition and Fetal Adaptation. ” JOG” 25(4): 339-349, 1996. Ludington-Hoe, S. M., and Swinth, J. Y. “Developmental Aspects of Kangaroo Care. ” JOGNN 25(8): 691- 703, 1996. Maloni, J. A., and Ponder, M. B. “Father's Experience of Their Partners' Antepartum Bed Rest. ” IWGE 29(2): 183-188, 1997. Maloni, J. A. “Bed Rest During Pregnancy: Implications for Nursing. ” JOGNN 22(5): 422-426, 1992. Miles, M. S. “Maternal Concerns About Parenting Prematurely Born Children. ” MCN 23(2): 70-75, 1998. Mitchell, A., et al. “Group B Streptococcus and Pregnancy: Update and Recommendations. ” MCN 22 (Sept/Oct): 242-248, 1997. “Neonatal Circumcision. ” AWHONN Clinical Commentary, The Association of Women's Health, Obstetric, and Neonatal Nurses, 1994. “Obstetric Epidural Analgesia and the Role of the Professional Registered Nurse. ” AWHONN Clinical Commentary, The Association of Women's Health, Obstetric, and Neonatal Nurses, 1996. “Pain in Neonates. ” AWHONN Clinical Commentarv, The Association of Women's Health, Obstetric, and Neonatal Nurses, 1995. Penny-Mac Gillivray, T. “A Newborn's First Bath: When?” JOGNN 25(6): 481-487, 1996. “Perinatal Group B Streptococcal Disease. ” AWHONN Clinical Commentarv, The Association of Women's Health, Obstetric, and Neonatal Nurses, 1996. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
REFERENCES 309 Schmidt, J. V. “Intrapartum Care of the Adolescent. ” 7 Health Nursing 1(2):132-138, 1995. Schroeder, C. A. “Women's Experience of Bed Rest in High-Risk Pregnancy. ” IMAGE 28(3): 253-258, 1996. Swanson, S. C., and Naber, M. M. “Neonatal Integrated Home Care: Nursing Without Walls. ” Neonatal Network 16(7): 33-38, 1997. Weber, S. E. “Cultural Aspects of Pain in Childbearing Women. ” JOGNN 2S(l): 67-72, 1996. Williams, L. R., and Cooper, M. K. “Nurse-Managed Postpartum Home Care. ” JOGNN 22( 1): 25-3 1, 1993. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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