Formulate a nursing care plan.
Case 2. INFANT WITH IUGR
James is a premature second twin born to a 34-year-old, gravida3, para 2. He was delivered by cesarean section for severe IUGR at33 weeks gestation. He was assigned an APGAR score of 7 at 1min and8 at 5mins. James weighed 1,180g at birth, head circumference was27cm, length was 38cm. All parameters were less than 10thpercentile. He was vigorous at birth, cried at delivery, and thendeveloped mild respiratory distress during the first few minutes oflife. He was given a whiff of oxygen for cyanosis afterdelivery.
James’ initial glucose level was 28mg/dl. A glucose test wasrepeated after he received an IV bolus of D10W and then was startedon a continues drip of the same IV fluid. The repeated level was 57mg/dl. James was started on feedings of extracted breastmilk on thesecond day of life. Oral feeding was started at gestational age of34 weeks.
James parents live in a small town about 50 miles from thehospital where the NICU is located. His mother was transported tothe obstetrical unit 3weeks before his delivery. They were involvedin his care as much as possible during his hospital stay. Jameswent home at 6 weeks of age.
|
Patient’s Name: |
Actual/ Provisional Diagnosis: |
|||||
|
Nursing Problem: |
||||||
|
Assessment |
Nursing Diagnosis |
Outcomes /Objectives |
Nursing Interventions |
Rationale |
Evaluation |
|
|
Subjective Data: Objective Data: |
(PES) |
(SMART) Long Term Objective Short term Objectives |
OM(idc)E |
(Rationale for each Intervention) |
||
