Pre-mature Birth

Pre-mature Birth

1. 2. Impaired nutrition related to esophageal reflux as evidenced by baby spitting up food.

   • Assessment Evidence: Patient drank approx. 60 ml of formula and spit up and saturate a burp cloth within an hour of finishing.
   • Intervention: Nurse will incline patient's bed.
     • Intervention: Nurse will administer patient's prescription for Prevacid.
       • Intervention: Nurse will burp patient after feedings.
         • Outcome: Patient continued to spit up throughout shift.

2. 3. Constipation related to dehydration as evidenced by lack of bowel movement.

   • Assessment Evidence: Patient passes gas regularly but has not had a bowel movement in the last 24 hrs.
   • Intervention: Nurse will feed infant 2ml of prescribed prune juice twice a shift.
     • Intervention: Nurse will change the patient's formula to one that aids with constipation per doctor's order.
       • Outcome: Patient did not have a bowel movement.

3. 1. Impaired gas exchange related to underdeveloped lungs as evidenced by tachypnea and low oxygen saturation.

   • Assessment Evidence: Patient's respiratory rate frequently escalated to 75-88/min throughout the day. Patient also had 1 liter of 30% oxygen via nasal cannula throughout the day.
   • Intervention: Nurse will ensure infant resuscitation equipment is nearby in case of respiratory emergency.
     • Intervention: Nurse will increase oxygen concentration and volume to 1.5 liters and 35%.
       • Intervention: Nurse will keep monitor on patient's foot for 24/7 observation.
         • Outcome: Patient remained stable throughout shift but still experienced de-sats and tachypnea.

4. 4. Interrupted family process related to baby being in the NICU as evidenced by infrequent family visits.

   • Assessment Evidence: the patient had no visitors in the last 24 hrs.
   • Intervention: Nurse will call parents to see if they would like to visit.
     • Intervention: Nurse will ask parents if they would like to meet with a social worker.
       • Outcome: Family did not come to visit during shift.