THE PRETERM INFANT

Any infant born prior to completing 37 weeks’ gestation is identified as premature. Thus, the level of
development and maturity, and often the degree of complications, varies within this group, dependent on the length of
gestation.

NEONATAL ASSESSMENT DATA BASE

Circulation
Apical pulse may be rapid and/or irregular within a normal range (120–160 bpm).
Audible heart murmur may indicate PDA.

Food/Fluid
Weight less than 2500 g (5 lb 8 oz).
Body long, thin, limp with a slight potbelly.
Suck/swallow reflex may be absent/uncoordinated (impacts feeding choices).

Neurosensory
Head size large in relation to body; sutures may be easily movable; fontanels may be large or wide open.
May demonstrate twitching or eye rolling.
Edema of eyelids common; eyes may be fused shut (depends on gestational age).
Reflexes depend on gestational age; rooting well established by 32 weeks’ gestation; coordinated reflexes for sucking,
swallowing, and breathing usually established by 32 wk; first component of Moro’s reflex (lateral extension of
upper extremities with opening of hands) appears at 28 wk; second two components (anterior flexion and audible
cry) appear at 32 wk.
Dubowitz examination indicates gestational age between 24 and 37 wk.

Respiration
Apgar scores may be low.
Respirations may be shallow, irregular; diaphragmatic with intermittent or periodic breathing (40–60/min).
Grunting, nasal flaring, suprasternal or substernal retractions, or varying degrees of cyanosis may be present.
Auscultatory presence of “sandpaper” sound indicates RDS.

Safety
Temperature fluctuates easily.
Cry may be weak.
Face may be bruised; caput succedaneum may be present; labor or delivery may have been precipitous.
Skin reddened or translucent; color may be pink/ruddy, acrocyanotic, or cyanotic/pale.
Lanugo widely distributed over entire body.
Extremities may appear edematous.
Sole creases may or may not be present on all or part of the foot.
Nails may be short.

Sexuality
Female labia minora may be larger than labia majora, with prominent clitoris.
Male testes may not be descended; rugae may be scant or absent on scrotum.

Teaching/Learning
Maternal history may reveal factors that contributed to preterm labor, such as young age; low socioeconomic
background; closely spaced pregnancies; multiple gestation; poor nutrition; previous preterm birth; obstetric
 complication such as abruptio placentae, premature rupture of membranes (PROM), premature dilation of cervix,
presence of infection; blood incompatibility associated with erythroblastosis fetalis; or use of prescription, over-
the-counter, or street drugs.

DIAGNOSTIC STUDIES
Choice of tests and the expected results depend on presenting problems and secondary complications.
Amniotic Fluid Studies: For lecithin-to-sphingomyelin (L/S) ratio, fetal lung profile, and phosphatidyl
glycerol/phosphatidyl inositol may have been performed during pregnancy to assess fetal maturity.
CBC: Decreases in Hb/Hct may be associated with anemia or blood loss. WBC count may be <10,000/mm3 with a
shift to the left (excess early neutrophils and bands), which is usually associated with severe bacterial disease.
Dextrostix: Reveals hypoglycemia. Serum glucose test may be required if Dextrostix result is 45 mg/ml.
Serum Calcium: May be low.
Electrolytes (Na+, K+, Cl -): Usually within normal limits initially, but susceptible to critical fluctuations.
Blood Type: May reveal potential for ABO incompatibility.
Rh and Direct Coombs’ Determination (if mother is Rh-negative and father is Rh-positive): Determines
incompatibilities.
ABGs: PO 2 may be low; PCO 2 may be elevated and reflect mild/moderate acidosis, sepsis, or prolonged respiratory
difficulties.
Erythrocyte Sedimentation Rate (ESR): Elevation indicates an acute inflammatory response. Diminishing ESR
indicates resolution of inflammation.
C-reactive Protein (a beta globulin): Present in serum in proportion to severity of infectious or noninfectious
inflammatory process.
Platelet Count: Thrombocytopenia may accompany sepsis.
Fibrinogen Levels: May decrease during disseminated intravascular coagulation (DIC) or become elevated during
injury or inflammation.
Fibrin Split Products: Present with DIC.
Blood Cultures: Identify causative organisms associated with sepsis.
Urinalysis (on second voided specimen): Detects abnormalities, renal injury.
Urine-Specific Gravity: Ranges between 1.006 and 1.013; elevated with dehydration.
Clinitest/Clinistix: Identifies presence of sugar in urine.
Hematest: Examines stools for blood; positive results suggest necrotizing enterocolitis.
Shake Test on Gastric Aspirate: Determines presence or absence of surfactant. (Intermediate results if blood or
meconium is present.)
Chest X-Ray (posteroanterior [PA] and lateral) with Air Bronchogram: May have ground-glass appearance
(RDS).
Serial Cranial Ultrasonography: Detects presence and severity of intraventricular hemorrhage (IVH).
Lumbar Puncture: May be performed to rule out meningitis.
Maternal GBS Status: Determines potential for meningitis/infections.

NURSING PRIORITIES
1. Promote optimal respiratory functioning.
2. Maintain neutral thermal environment.
3. Prevent or reduce risk of potential complications.
4. Maintain homeostasis.
5. Foster development of healthy family unit.
DISCHARGE GOALS
1. Maintaining physiological and behavioral homeostasis with minimal external support.
2. Weight 41/2 lb or greater appropriate to age/condition.
3. Complications prevented/resolving or independently managed.
4. Family identifying and using resources appropriately.
5. Family demonstrates ability to manage infant care.
6. Plan in place to meet needs after discharge.
 NURSING DIAGNOSIS: GAS EXCHANGE, impaired
May Be Related To: Ventilation perfusion imbalances, inadequate surfactant levels,
immaturity of pulmonary arteriole musculature, immaturity of CNS
and neuromuscular system, airway congestion, anemia, and cold
stress
Possibly Evidenced By: Hypercapnia, hypoxia, tachypnea, cyanosis
DESIRED OUTCOMES/EVALUATION Maintain PO 2/PCO 2 levels WNL.
CRITERIA—NEONATE WILL:
Suffer minimal RDS, with reduced work of breathing and no
morbidity.
Be free of bronchopulmonary dysplasia.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Review information related to infant’s condition, Prolonged labor increases risk of hypoxia, and
such as length of labor, type of delivery, Apgar respiratory depression may follow maternal drug
score, need for resuscitative measures at delivery, administration or usage. In addition, infants who
and maternal medications taken during pregnancy required resuscitative measures at birth, or those
or delivery, including betamethasone. with low Apgar scores, may require more intense
interventions to stabilize blood gases and may have
suffered CNS injury with damage to the
hypothalamus, which controls respiratory
functioning. Note: Administration of corticosteroids
to mother within 1 wk of delivery fosters the infant’s
lung maturity and surfactant production.

Note gestational age, weight, and sex. Neonates born before 30 weeks’ gestation and/or
weighing less than 1500 g are at higher risk for
developing RDS. In addition, males are twice as
susceptible as females. Note: The majority of deaths
related to RDS occur in infants weighing less than
1500 g.

Assess respiratory status, noting signs of Tachypnea indicates respiratory distress,

respiratory distress (e.g., tachypnea, nasal especially when respirations are >75/min after
flaring, grunting, retractions, rhonchi, or crackles). the first 5 hr of life. Expiratory grunting represents an
attempt to maintain alveolar expansion; nasal flaring
is a compensatory mechanism to increase diameter of
nares and increase oxygen intake. Crackles/rhonchi
may indicate pulmonary vasocongestion associated
with PDA, hypoxemia, acidemia, or immaturity of
muscles in arterioles, which fail to constrict in
response to increased oxygen levels.

Apply transcutaneous oxygen monitor or pulse Provides constant noninvasive monitoring of

oximeter. Record levels hourly. Change site of oxygen levels. Note: Pulmonary insufficiency
probe every 3–4 hr. usually worsens during the first 24–48 hr, then
reaches a plateau.
Suction nares and oropharynx carefully, as needed. May be necessary to maintain airway patency,
Limit time of airway obstruction by catheter to especially in infant receiving controlled
5–10 sec. Observe transcutaneous oxygen monitor ventilation. Preterm infant does not develop the
or pulse oximeter before and during suctioning. coordinated reflex for sucking, swallowing, and
Provide “bag” ventilation following suctioning. breathing until 32–34 weeks’ gestation. Cilia may not
be fully developed or may be damaged from use of
endotracheal tube. Exudate phase associated with
RDS at about 48 hr postpartum may contribute to
infant’s difficulty in handling secretions. Suctioning
may stimulate vagus nerve, causing bradycardia,
hypoxemia, or bronchospasm. Bag ventilation
promotes rapid restoration of oxygen levels.
Maintain thermal neutrality with body temperature Cold stress increases infant’s oxygen consumption,
at 97.7°F (± 0.5°F). (Refer to ND: Thermoregulation, may promote acidosis, and may further impair
ineffective.) surfactant production.
Monitor fluid intake and output; weigh infant as Dehydration impairs ability to clear airways
indicated by protocol. because mucus becomes thickened. Overhydration
may contribute to alveolar infiltrates/pulmonary
edema. Weight loss and increased urine output may
indicate diuretic phase of RDS, usually beginning at
72–96 hr and preceding resolution of condition.
Promote rest; minimize stimulation and energy Reduces metabolic rate and oxygen consumption.
expenditure.
Position infant on abdomen if possible. Provide Prone position compensates for weak chest and
“rocker” mattress, as indicated. abdominal muscles, decreasing the amount of
respiratory effort required to expand chest, thus
allowing optimal chest expansion and enhancing
inhalation of air. Stimulates respirations and
ventricular growth. Positioning infant on abdomen or
side reduces risk of aspiration of mucus/regurgitated
formula.
Observe for evidence and location of cyanosis. Cyanosis is a late sign of low PaO 2 and does not
appear until there are slightly more than 3 g/dl of
reduced Hb in central arterial blood, or 4–6 g/dl in
capillary blood, or until oxygen saturation is only
75%–85%, with PO 2 levels of 32–41 mm Hg.
Therefore, prompt intervention is crucial.
Investigate sudden deterioration in condition Sudden or unexplained deterioration of
associated with cyanosis, diminished or absent respiratory function may indicate onset of
breath sounds, shift of point of maximal impact pneumothorax.
(PMI), bulging of chest wall, hypotension,
or cardiac dysrhythmias.
Monitor for signs of necrotizing enterocolitis. Hypoxia may cause shunting of blood to brain,
(Refer to ND: Constipation/Diarrhea, risk for.) thereby reducing circulation to the intestines, with
resultant intestinal cell damage and invasion by gas-
forming bacteria.

Collaborative
Monitor laboratory/diagnostic studies,
as appropriate:
Graph serial ABGs; Hypoxemia, hypercapnia, and acidosis reduce
surfactant production. PaO 2 levels should be 50–70
 mm Hg or higher, PaCO 2 levels should be 35–45 mm
Hg, and oxygen saturation should be 92%–94%.
Hb/Hct; Decreased iron stores at birth, repeated blood
sampling, rapid growth, and hemorrhagic episodes
increase the likelihood that preterm infant will be
anemic, thereby reducing the oxygen-carrying
capacity of the blood. Note: Administration of
packed cells may be necessary to replace blood
drawn for laboratory studies.
Serial chest x-rays. Atelectasis, congestion, or air bronchogram suggests
developing RDS.

Administer supplemental oxygen, as needed, by Hypoxemia and acidemia may further decrease
mask, hood, endotracheal tube, or mechanical surfactant production, increase pulmonary
ventilation using constant positive airway vascular resistance and vasoconstriction, and
pressure (CPAP) and intermittent mandatory cause ductus arteriosus to remain open.
ventilation (IMV), or intermittent positive- Immaturity of the hypothalamus may necessitate
pressure breathing (IPPB) and positive end- ventilatory assistance to maintain respirations. Use
expiratory pressure (PEEP). of PEEP may reduce airway collapse, enhancing gas
exchange and reducing the need for high levels of
oxygen.

Monitor oxygen therapy closely. Record fraction of Amount of oxygen administered, expressed as
oxygen in inspired air (FIO2) every hour. Adjust FIO2, is determined individually, based on
level and/or limit duration of administration transcutaneous monitoring or capillary blood
as appropriate. samples. Prolonged high levels of serum oxygen
combined with prolonged high pressures resulting
from IPPB and PEEP (barotrauma) may predispose
infant to bronchopulmonary dysplasia and retinal
damage. Note: The retina has an immature vascular
system that is susceptible to damage, leading to vaso-
obliteration. New vessels that are developing may
rupture, creating retinal and vitreous hemorrhage,
leading to formation of scar tissue.

Initiate postural drainage, chest physiotherapy, Facilitates removal of secretions. Length of time
or lobe vibration every 2 hr, as indicated, noting allotted to each lobe is related to infant’s tolerance.
infant’s tolerance of procedure. (Infant usually cannot tolerate a full treatment
regimen each time.)

Aspirate gastric contents for shake test. Provides immediate information about presence of
surfactant. Surfactant, which is necessary to promote
normal expansion and elasticity of alveoli, is usually
not present in sufficient quantities until 32–33 weeks’
gestation.

Provide feedings by nasogastric or orogastric Reduces oxygen needs, promotes rest, conserves
tube instead of nipple feedings, as appropriate. energy, and reduces risk of aspiration caused by
poorly developed gag reflex.

Administer medications as indicated:

Sodium bicarbonate; If measures to increase respiratory rate or improve
ventilation are not sufficient to correct acidosis,
cautious use of sodium bicarbonate may help return
pH to normal range. Note: Adequate circulation (HR
>100) must be established.
 Surfactant (artificial or exogenous). May be given at birth or after diagnosis of RDS to
decrease severity of condition and associated
complications. Effect may last up to 72 hr.
Assist with procedures as needed:
Needle aspiration, thoracentesis, or Reinflates lung enough through removal of
chest tube insertion; trapped air or fluid, reestablishing negative pressure
and enhancing gas exchange.
Indirect ophthalmoscopic fundal exam; Recommended for all infants less than 36 weeks’
gestation or under 2000 g and receiving oxygen
therapy. Usually done between 4 and 8 wk of age and
repeated as indicated to diagnose/monitor
progression of retinopathy of prematurity and
determine therapy needs.
Laser therapy or cryotherapy. May be useful in limiting adverse effects associated
with acute stages of retinopathy of prematurity by
obliterating newly forming vessels, reducing traction
on the retina and subsequent detachment, and
limiting creation of new vessels.

NURSING DIAGNOSIS: BREATHING PATTERN, ineffective

May Be Related To: Immaturity of the respiratory center, limited mus-cular development,
decreased energy/fatigue, drug-related depression, and metabolic
imbalances
Possibly Evidenced By: Dyspnea, tachypnea, periods of apnea, nasal flaring, use of accessory
muscles, cyanosis, abnormal ABGs, tachycardia
DESIRED OUTCOMES/EVALUATION M aintain periodic breathing pattern (apneic
CRITERIA—NEONATE WILL: periods last 5–10 sec, followed by short periods of rapid ventilation),
with mucous membranes pink, and heart rate 110–160/respiratory
rate 24–60.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Assess respiratory rate and breathing pattern. Helps in distinguishing normal cyclic periodic
Note presence of apnea and changes in heart breathing pattern from true apneic spells, which
rate, muscle tone, and skin color associated with are particularly common prior to 30 weeks’
procedures or care. Institute continuous respiratory gestation.
and cardiac monitoring.
Suction airway as needed. Removes mucus obstructing the airway to maximize
respiratory effort.
Review maternal history for drugs that might Magnesium sulfate and narcotics depress
contribute to respiratory depression in the infant. respiratory center and CNS activity.
Position infant on abdomen or in supine position Such positioning may facilitate respiration and
with rolled diaper beneath shoulders to produce reduce apneic episodes, especially in the presence
slight hyperextension. of hypoxia, metabolic acidosis, or hypercapnia.
Maintain optimal body temperature. (Refer to ND: Even a slight increase or decrease in
Thermoregulation, risk for ineffective.) environmental temperature can lead to apnea.
Provide prompt tactile stimulation (e.g., rub Stimulates CNS to promote body movement and
infant’s back) if apnea occurs. Note presence of spontaneous return of respirations. Sometimes,
cyanosis, bradycardia, or hypotonia. Encourage infants experience fewer or no episodes of apnea
parental contact. or bradycardia if parents touch and talk to them.
Place infant on neowave mattress. Movement provides stimulation, which may reduce
apneic episodes.

Collaborative
Monitor laboratory studies (e.g., ABGs, serum Hypoxia, metabolic acidosis, hypercapnia,
glucose, electrolytes, cultures, and drug levels) hypoglycemia, hypocalcemia, and sepsis may
as indicated. contribute to apneic spells. Drug toxicity, which
depresses respiratory function, may occur because of
limited excretion and prolonged drug half-life.

Administer supplemental oxygen, as indicated. Correction of oxygen and carbon dioxide levels
(Refer to ND: Gas Exchange, impaired.) may improve respiratory function.

Administer medications, as indicated:

Sodium bicarbonate; Judicious use may be required to help correct
acidosis, especially after hypoxic episodes, because
bicarbonate is excreted at lower serum levels and
immature kidneys are slower to excrete lactic acid.
Antibiotics; Treat respiratory infection or sepsis.
Calcium gluconate; Hypocalcemia predisposes infant to apnea.
Aminophylline; May increase activity of respiratory center and lower
sensitivity to carbon dioxide, reducing frequency of
apnea.
Pancuronium bromide (Pavulon); Induces skeletal muscle relaxation, which may be
necessary if infant is to be mechanically ventilated.
Glucose solutions. Prevent hypoglycemia. (Refer to ND: Nutrition:
altered, risk for less than body requirements.)

NURSING DIAGNOSIS: THERMOREGULATION, ineffective

May Be Related To: Immature CNS development (temperature regulation center),

decreased ratio of body mass to surface area, decreased subcutaneous
fat, limited brown fat stores, an inability to shiver or sweat,
limited/inability to flex extremities, poor metabolic reserves (limited
glycogen stores), thinner skin, muted response to hypothermia, and
frequent medical/nursing manipulations and interventions

Possibly Evidenced By: Fluctuation of body temperature below/above normal range

Tachypnea/apnea, generalized cyanosis, bradycardia, lethargy (cold
stress)
Tachycardia, flushed color, lethargy, apnea (hyperthermia)
DESIRED OUTCOMES/EVALUATION Maintain skin/axillary temperature within
CRITERIA—NEONATE WILL: 97.7°F–99.1°F (36.5°C–37.3°C).
Be free of signs of cold stress.
ACTIONS/INTERVENTIONS RATIONALE

Independent
Assess temperature frequently. Check rectal Hypothermia predisposes infant to cold stress,
temperature initially; thereafter, check axillary utilization of nonrenewable brown fat stores if
temperature or use thermostat probe with open present, and reduced sensitivity to increased levels
bed and radiant warmer. Repeat every 15 min of carbon dioxide (hypercapnia) or decreased
during rewarming. oxygen levels (hypoxia). Note: Too rapid rewarming
is associated with apneic states. This causes further
respiratory depression instead of increased
respiratory rate, leading to apnea and reduced
oxygen uptake.
Ascertain medications mother received during Fetal hypoxia or maternal use of meperidine
prenatal and intrapartal periods. Note presence (Demerol) alters fetal metabolism of brown fat,
of fetal distress or hypoxia. often causing significant drop in neonate’s
temperature. Magnesium sulfate can cause
vasodilation and interfere with infant’s ability to
retain heat.

Place infant in warmer, Isolette, incubator, open Maintains thermoneutral environment, helps
bed with radiant warmer, or open crib with prevent cold stress.
appropriate clothing for larger or older infants.
Use heating pad under infant as necessary, in
conjunction with Isolette or open bed.

Use heat lamps during procedures. Warm objects Decreases loss of heat to the cooler environment of
coming in contact with infant’s body, such as the room/treatment surfaces, or by infusion of
stethoscopes, linens, and clothing. Use blanket/ chilled blood.
diaper to pad cold surfaces such as scale,
examination table, x-ray plate, and hands. Surround
infant with warmed receiving blankets. Cover
radiant warmers with plastic wrap, if appropriate.
Warm blood products, if administered.

Reduce exposure to drafts; avoid unnecessary Reduces heat losses due to convection/
opening of portholes in Isolette. conduction. Limits heat losses from radiation.
Change clothing or bed linens when wet. Keep Decreases evaporative losses.
infant’s head covered.
Note environmental temperature/monitor Hyperthermia with resultant increases in
temperature-regulating system, radiant warmers, metabolic rate, oxygen and glucose needs, and
or incubators. (Maintain upper limit at 98.6°F insensible water losses can occur when controlled
[37°C], depending on infant’s size or age.) environmental temperatures are too high.
Conversely, a decrease in the environmental
temperature of 3.6°F (2°C) also results in significant
increase of oxygen consumption and glucose needs.
Maintain relative humidity of 50%–80%. Warm Prevents excessive evaporation, reducing
humidified oxygen to 88°F–93°F (31°C–34°C). insensible fluid losses.
Note presence of tachypnea or apnea; generalized These signs indicate cold stress, which increases
cyanosis, acrocyanosis, or mottled skin; oxygen and caloric consumption and predisposes
bradycardia, poor cry, or lethargy. Evaluate infant to acidosis associated with anaerobic
degree and location of jaundice. (Refer to metabolism. Hypothermia increases risk of
CP: Newborn: Hyperbilirubinemia.) kernicterus, as fatty acids released with brown fat
metabolism compete with bilirubin for binding sites
on albumin. Note: Skin color may be bright red
peripherally, with cyanosis noted centrally as a result
of failure of dissociation of oxyhemoglobin.
Provide gradual warming for infant with cold stress. Rapid increase in body temperature may cause
excessive oxygen consumption and apnea.
Measure urine output and specific gravity. Reduced urine output and increased specific gravity
of urine are related to reduced kidney perfusion
during periods of cold stress. Note: Use of radiant
heat for warming, for longer than a few hours,
potentiates water loss decreasing circulating volume
and renal perfusion.
Monitor serial weight gain. If weight gain is Inadequate weight gain despite sufficient caloric
inadequate, increase environmental temperature intake may indicate that calories are being used to
as indicated. maintain body temperature, necessitating increased
environmental temperature. Note: Excessive
warming also increases metabolic demands as infant
attempts to cool down.
Note frequency and amount of food intake. Poor feeding is common in infants with thermal
Monitor Dextrostix. Assess infant for vomiting, instability; in addition, cold stress increases
abdominal distension, or apathy. consumption of metabolic reserves. Dextrostix levels
<45 mg/dl indicate hypoglycemia, necessitating
prompt intervention.
Assess infant’s progressive ability to adapt to Bassinet may be used when infant can maintain
lowered temperatures in incubator or Isolette, stable body temperature of 97.7°F (36.5°C) in room
or to room temperature, while demonstrating air and still gain weight.
appropriate weight gains.
Monitor infant’s temperature when out of warmed Out-of-bed contact, especially with parents, may
environment. Provide parents with information need to be brief, if allowed at all, to prevent cold
about thermoregulation. stress. Note: Hyperthermia can also occur when
infant is held by parents.
Note development of tachycardia, flushed color, These signs of hyperthermia (body temperature
diaphoresis, lethargy, apnea, coma, or seizure 99°F [37.2°C]) can progress to brain damage,
activity. if untreated.
Evaluate external sources of heat (e.g., These measures are generally successful in
phototherapy, heat lamp, or sunlight), limit correcting hyperthermia. Note: If hyperthermia
clothing, and provide tepid sponge bath, persists after assuring proper position and
as appropriate. Verify proper positioning of functioning of temperature probe, the possibility
temperature probe, if used. of a hypermetabolic state such as sepsis or narcotic
withdrawal should be considered.
Collaborative
Monitor pulse oximetry, laboratory studies, as Cold stress increases the needs for glucose and
indicated (e.g., ABGs, serum glucose, electrolytes, oxygen and may result in acid-base problems if
and bilirubin levels). (Refer to ND: Gas Exchange, infant resorts to anaerobic metabolism when
impaired.) sufficient oxygen levels are not available. Elevated
indirect bilirubin levels may occur because of the
release of fatty acids from brown fat metabolism,
with fatty acids competing with bilirubin for binding
sites on albumin. Metabolic acidosis may also occur
with hyperthermia.
Administer D10W and volume expanders IV, Administration of dextrose may be necessary to
as needed. correct hypoglycemia. Hypotension caused by
peripheral vasodilation may require treatment in
heat-stressed infant. Hyperthermia may cause a
threefold to fourfold increase in dehydration.
Provide supplemental oxygen as indicated. If oxygen is not readily available to meet increased
metabolic needs associated with efforts to increase
body temperature, the infant will use anaerobic
metabolism, resulting in acidosis caused by lactic
acid buildup. Hypothermia reduces the preterm
infant’s response to hypoxia and hypercapnia, which
causes further respiratory depression instead of
increased respiratory rate, leading to apnea and
reduced oxygen uptake. Hyperthermia caused by too
rapid/excessive warming is associated with apneic
states, increased insensible water losses, and
increased metabolic rates with increased demands for
oxygen and glucose.
Administer medications, as indicated:
Phenobarbital; Helps prevent seizures associated with CNS irritation
caused by hyperthermia.
Sodium bicarbonate. Corrects acidosis, which may occur with both
hypothermia and hyperthermia.

NURSING DIAGNOSIS: FLUID VOLUME, risk for deficit

Risk Factors May Include: Extremes of age and weight (premature, under 2500 g), excessive fluid
losses (thin skin, lack of insulating fat, increased environmental
temperature, immature kidney/failure to concentrate urine)
Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual
diagnosis]
DESIRED OUTCOMES/EVALUATION Be free of signs of dehydration or glycosuria with
CRITERIA—NEONATE WILL: fluid intake approximating output and pH, Hct, and urine specific
gravity WNL.
Display weight gain of 20–30 g/day.
ACTIONS/INTERVENTIONS RATIONALE

Independent
Obtain daily serial weights using same scale at Weight is the most sensitive indicator of fluid
same time of day. balance. Weight loss should not exceed 15% of total
body weight or 1%–2% of total body weight per day.
Inadequate weight gain may be related to water
imbalance or inadequate caloric intake.
Calculate fluid balance (total intake minus total Output should be 1–3 ml/kg/hr, while fluid
output) each shift and cumulative balance each therapy needs are approximately 80–100 ml/kg/
24-hr period. Maintain hourly records of infusing day on the 1st day of life, increasing to 120–140
IV fluids/feedings. Determine output through ml/kg/day by the 3rd day after delivery. Lower
measuring urine from collecting bag or through gestational age has a negative impact on the
weighing/counting diapers. Also record amount glomerular filtration rate (GFR) and is further
of blood taken for laboratory testing. limited by conditions that impair renal blood flow or
oxygen content (e.g., dehydration, respiratory
distress), often resulting in oliguria/anuria. Positive
fluid balance and corresponding weight gain in
excess of 20–30 g/day suggest fluid excess.
Measure urine specific gravity after each voiding, Although renal immaturity and inability to
or every 2–4 hr, by aspirating urine from diaper concentrate urine usually result in low specific
if infant cannot tolerate adhesive or urine gravity in the preterm infant (normal range is
collecting bag. 1.006–1.013), urine specific gravity may vary,
providing an indication of the level of hydration.
Low levels indicate excessive fluid volume; levels
>1.013 indicate insufficient fluid intake and
dehydration.
Test urine with Dextrostix per protocol. Even in cases of hypoglycemia, glycosuria occurs as
immature kidneys begin excreting glucose, which
may lead to osmotic diuresis, increasing risk of
dehydration.
Minimize insensible fluid losses through use of Preterm infant loses large amounts of water
clothing, thermoneutral temperatures, and warm through skin, because blood vessels are close to
or humidified oxygen. surface and insulating fat levels are decreased or
absent. Phototherapy or use of radiant warmer may
increase insensible losses by 50%, necessitating
increased intake to as much as 200 ml/kg/day. Note:
Infants weighing <1500 g (3 lb 5 oz) are most
susceptible to insensible fluid losses.
Monitor BP, pulse, and mean arterial pressure A loss of 25% of blood volume results in shock, with
(MAP). MAP of less than 25 mm Hg indicating hypotension.
Note: BP is related to weight, that is, the smaller the
baby, the lower the MAP.
Evaluate skin turgor, mucous membranes, and Fluid reserves are limited in the preterm infant.
status of anterior fontanel. Minimal fluid losses/shifts can quickly lead to
dehydration, as noted by poor skin turgor, dry
mucous membranes, and depressed (sunken)
fontanels.
Note lethargy, high-pitched cry, abdominal These signs reflect hypocalcemia, which is most
distension, increased apnea, twitching, hypotonia, likely to occur during the first 10 days of life.
or seizure activity.
Assess IV site every hour. Note edema or failure of Swelling may indicate that infiltration of fluid is
fluid infusion. Do not check needle position by occurring or that tape is too tight. Back-up of
lowering fluid below needle level. blood caused by lowering fluid may clog needle.
Monitor infusion rate closely and use pumps to Verifies accuracy of infusion rate to meet
administer fluids. individual needs of infant and to prevent excess
intake. Note: Limited ability of kidneys to excrete
excess fluid increases risks of overhydration with
cardiac or respiratory involvement as noted by
presence of crackles, rhonchi, dyspnea, tachypnea,
and/or peripheral edema.
Institute measures to prevent infection. (Refer to Infection places increased demands on an already-
ND: Infection, risk for.) compromised renal system.

Collaborative
Monitor laboratory studies as indicated:
Hct; Dehydration increases Hct level beyond the normal
reading of 45%–53%. Removal of blood for testing
causes reduction in Hb/Hct levels.
Serum calcium and serum magnesium; Preterm infant is susceptible to hypocalcemia
(calcium level <7 mg/dl) because of low stores,
depressed parathyroid stimulation, and stress caused
by hypoxia, sepsis, or hypoglycemia.
Hypomagnesemia often accompanies hypocalcemia.
Serum potassium; Hypokalemia may occur because of losses through
nasogastric tube, diarrhea, or vomiting. Excessive
levels of potassium (hyperkalemia) can result from
replacement errors, potassium shifts from
intracellular to extracellular compartments, acidosis,
or renal failure.
Blood urea nitrogen (BUN), creatinine, and Assesses adequacy of kidney function.
uric acid levels.
Administer parenteral infusions in amounts Fluid replacement expands blood volume; helps
180 ml/kg, especially in PDA, reverse vasoconstriction associated with hypoxia,
bronchopulmonary dysplasia (BPD), or acidosis, and right-to-left shunting through PDA;
necrotizing enterocolitis (NEC). and has been helpful in reducing complications of
NEC and BPD.
Administer potassium chloride, 10% calcium Correction of electrolyte imbalances is necessary to
gluconate, and 50% magnesium sulfate, as maintain or achieve homeostasis. Calcium
indicated. Monitor infant for potential bradycardia administered through umbilical venous catheter
via cardiac monitor; observe infusion site for signs may cause liver necrosis; if administered through
of irritation or edema. umbilical artery, it may contribute to NEC. Early
recognition and prompt intervention may limit
untoward effects of infiltration of medication, such as
sloughing, calcification, and necrosis. Note: Calcium
replacement is ineffective in presence of magnesium
deficit.
Administer blood transfusions. May be necessary to maintain optimal Hb/Hct levels
and replace blood losses.
Administer dopamine hydrochloride, as indicated. May be used to counteract drops in blood pressure,
especially when related to administration of
pancuronium (Pavulon).
 NURSING DIAGNOSIS: NUTRITION: altered, risk for less than body requirements
Risk Factors May Include: Immaturity of enzymatic production; reduced production of
hydrochloric acid (reduces absorption of fat and fat-soluble vitamins);
immaturity of the cardiac sphincter; lax abdominal muscles; small
stomach capacity; weak, absent, or unsynchronized reflexes
associated with feeding; inadequate levels of stored nutrients
Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual
diagnosis]
DESIRED OUTCOMES/EVALUATION Maintain growth and weight gain in a normal
CRITERIA—NEONATE WILL: curve, with steady weight gain of at least 20–30 g/day.
Maintain serum glucose WNL and positive nitrogen balance.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Assess maturity of reflexes associated with feeding Determines appropriate feeding method for infant.
(ie., sucking, swallowing, gag, and
coughing).
Auscultate for presence of bowel sounds. Assess The first feeding in a stable infant with peristalsis
physical state and respiratory status. can begin 3–6 hr following birth. If respiratory
distress is present, parenteral fluids are indicated,
and oral fluids should be withheld.
Initiate intermittent or tube feedings, as indicated. Gavage feedings may be necessary to provide
adequate nutrition in infant who has a poorly
coordinated suck-and-swallow reflex or who
becomes fatigued during oral feedings. Note:
Transition to oral feeding is significantly delayed if
apneic episodes are experienced.
Assess infant for proper placement of feeding Improper placement of tube in trachea can
tube; use appropriate clamping procedures to compromise respiratory function. When 1 ml or
prevent entry of air into stomach. less is aspirated from the stomach, this sum should
be subtracted from the feeding and reinstilled in
tube. When more than 2 ml is aspirated, feeding
schedule may need to be altered.
Instill breast milk/formula slowly over 20 min at Too-rapid entry of feeding into stomach may cause
a rate of 1 ml/min. rapid rebound response with regurgitation, increased
risk of aspiration, and abdominal distension, all of
which compromise respiratory status.
Assess energy level and expenditure, degree of Excessive expenditure of energy during feedings
fatigability, respiratory rate, and length of time reduces calories available for normal growth and
needed for feedings. development. Total or intermittent use of tube feedings
may be necessary to reduce fatigue. Oral feedings are
not appropriate if respiratory rate is >70/min.
Minimize social interaction stimuli other than Excessive stimulation may interfere with feeding,
those directly related to feeding if infant displays so that the necessary stimuli must be provided
signs of sensory overload. Reduce stimuli prior between feedings. Overstimulation prior to
to feedings. feedings may negatively affect sucking and GI
motility and may cause vomiting or regurgitation.
Provide pacifier during tube feedings. (If baby is Accommodates infant’s need for sucking. Provides
going to be breastfed eventually, mother may rub oral satisfaction so that infant associates self-
pacifier on breast, moistening it with a dab of gratification in sucking with comfort of filling
breast milk to scent it. She may also hold the stomach.
baby during feedings.)
Position infant on right side or prone, with head Facilitates gastric emptying and prevents reflux.
of mattress elevated 30 degrees.
Postpone postural drainage for at least 1 hr Allows optimal ingestion and absorption of
after feeding. feeding; helps prevent regurgitation associated with
increased handling.
Note presence of diarrhea, vomiting, regurgitation, Indicates impaired gastric function. Gastric
excessive gastric residual, or positive result of residual greater than 2 ml (aspirated via gavage
guaiac test. (Refer to ND: Constipation/Diarrhea, tube before feedings) suggests a need to reduce
risk for.) amount of feedings and may indicate poor
absorption or NEC.
Monitor Dextrostix levels and urine Clinitest Because the immature liver does not store or
per protocol. release glycogen well, risk of hypoglycemia is
increased. Hypoglycemia can be diagnosed by a
Dextrostix level <45 mg/dl. Note: Infant may be
asymptomatic, even when Dextrostix results are as
low as 20 mg/dl.
Maintain thermoneutral environment and Cold stress, hypoxia, and excessive handling
appropriate oxygenation of tissues. Disturb increase infant’s metabolic rate and caloric needs,
infant as little as possible. possibly sacrificing growth and weight gains.
Monitor infant for local or systemic reactions to About 50% of complications associated with total
parenteral feeding (e.g., increased temperature, parenteral nutrition (TPN) are caused by sepsis,
dyspnea, vomiting, cyanosis, or blood vessel usually Candida septicemia. Other complications
thrombosis). include fluid overload and obstruction or
dislodgement of catheter.
Record growth by plotting daily weight and Growth and weight gain are criteria for
weekly measurements of body length and establishing caloric requirements, for adjusting
head circumference. formula, and for determining frequency of feedings.
Growth spurts increase caloric requirements and
protein needs.
Encourage/support mother’s efforts to pump Breast milk is easy to digest (reduces potential for
and collect own breast milk. Identify NEC), and research suggests it boosts infant
additional resources. immunities and is associated with reduced
occurrence of allergic food reactions, fewer ear
infections, lower rate of childhood cancer. Note:
There are seven breast-milk banks that can be
contacted through the Human Milk Banking
Association of North America (Fax 1-860-232-0113) to
obtain supplements for infant, educational material,
or to refer mother as potential donor if infant is not
able to use breast milk presently and mother wishes
to maintain lactation.
Collaborative
Start feedings of sterile water, glucose, and breast Early feedings prevent depletion of reserves.
milk or formula, as appropriate.
Feed as frequently as indicated based on infant’s Infants <1250 g (2 lb 12 oz) are usually fed every
weight and estimated stomach capacity. 2 hr; infants between 1500 and 1800 g (3 lb 8 oz to
4 lb) are fed every 3 hr.

Use concentrated formula to provide 120–150 cal/ Calorie intake must be sufficient to prevent
kg/day or more, with 3–4 g/kg/day of protein. catabolism. Concentrated formulas/fortified breast
Add human milk fortifiers (HMF) to breast milk milk supply more calories in less volume, which is
for gavage feeding, as needed. necessary because of reduced gastric capacity and
emptying, and the danger of stressing immature
kidneys. Note: Sick infants may require half-strength
formula initially with volume/concentration
advanced over 1–10 days, as infant tolerates.

Administer supplemental vitamins and minerals, Replaces low nutrient stores to promote adequate
especially vitamins A, C, D, and E, and iron, nutrition and reduce risk of infection. Vitamin C may
as indicated. reduce susceptibility to hemolytic anemia and
alleviate BPD and retrolental fibroplasia. Vitamin D
facilitates retention of calcium and increased bone
density. Vitamin E helps prevent RBC hemolysis and
corrects deficiencies associated with use of iron-
fortified formulas and diet high in polyunsaturated
fats.

Maintain patency; assist with change of indwelling Provides continuous infusion of formula in very
feeding tube (transpyloric, nasojejunal, small preterm infants who meet specific criteria;
nasoduodenal tubes). e.g., tachypnea, chronic lung disease, respirator
dependence, recurrent aspiration, or repeated
elevated gastric residuals with other feeding
approaches. Note: Potential risks accompanying use
of these indwelling tubes (e.g., gastric/intestinal
perforation) must be weighed against benefits.

Administer TPN feedings via infusion pump TPN infusion of protein hydrolysate, glucose,
using indwelling catheter into vena cava or electrolytes, minerals, and vitamins may be
peripheral line. Infuse fat emulsions (Intralipid) necessary for infant with chronic diarrhea;
through peripheral line. malabsorption syndrome; surgical repair of GI
anomalies, obstruction, or NEC; or extreme
prematurity. Intralipid infusion provides essential
fatty acids to infant receiving TPN. Note: Benefits of
using Intralipid must be weighed against possible
risk of fat accumulation in the lungs.

Monitor laboratory studies, e.g., serum glucose, Measures necessity for and effectiveness of TPN
electrolytes, total protein, prealbumin. administration.

NURSING DIAGNOSIS: INFANT BEHAVIOR, risk for disorganized

Risk Factors May Include: Prematurity (immaturity of CNS system, hypoxia), environmental
overstimulation, invasive/painful procedures and therapies, separation
from parent(s)
 Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual
diagnosis]
DESIRED OUTCOMES/EVALUATION Exhibit organized behaviors that allow the
CRITERIA—NEONATE WILL: achievement of optimal potential for growth and development as
evidenced by modulation of physiological, motor, state, and
attentional-interactive functioning.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Determine infant’s chronological and develop- Useful in choosing interventions to meet specific
mental age; note length of gestation. Assess needs of infant and reduce detrimental
individual behaviors using appropriate tool environmental stimuli. The APIB scale measures five
(e.g., assessment of Preterm Infant Behavior Scale). areas of developmental behaviors, autonomic, motor
control, state differentiation, attention maintenance
and social interaction, self-regulation.
Provide a primary nurse for each shift. (Assign Promotes continuity of care and follow-through
one primary nurse per baby to provide information with developmental program. Enhances
to parents.) recognition of subtle changes in infant’s behavior and
condition. Consistent and predictable care enables
infant to develop trust in caregiver, environment, and
self and facilitates coping. Multiple caretakers
confuse the infant, increase distress during feeding,
cause irritability, and upset usual attention. Note:
Having one nurse responsible for giving information
helps to reduce instances of parents’ being
uninformed or misunderstanding.
Create womblike atmosphere whenever possible Providing dark, quiet environment reduces stress,
by covering Isolette for extended periods, playing promotes adaptation, and has been found to
recorded placental or maternal heart sounds, and correlate positively with weight gain, early
surrounding infant with rolled blankets or weaning from oxygen or ventilators, and earlier
manufactured “nesting” device. discharge. Recorded maternal heart sounds tend to
reduce or eliminate infant’s perception of noise from
the Isolette. Nesting position facilitates hand-to-
mouth behavior for self-consoling.
Cover top of radiant warmer with plastic wrap, Reduces environmental stress from air currents,
if appropriate. which startle the infant as personnel move past the
warmer.
Reposition infant using rolled diapers placed at Neuromuscular immaturity can impair infant’s
the back and front, if infant is in lateral position, ability to seek a position of comfort or to relieve
or at sides, if infant can tolerate a prone position. stress through repositioning. Rolled diapers
surrounding baby provide a sense of security and
have a calming effect. Prone position promotes sleep
and optimal relaxation.
Change infant’s position periodically (especially Provides kinesthetic stimulation. Neuromuscularly
if infant has nasal CPAP or endotracheal tube). immature infant is unable to reposition self or move
about in the Isolette.
Use containment measures when handling/moving Using hands to hold infant’s arms and legs in
infant and avoid sudden postural changes. flexed position close to midline of body helps
stabilize infant’s motor and physiological
subsystems.
Provide gentle stroking and caressing, especially at Provides tactile stimulation, which is associated
feeding time, introducing textures (tongue blade, with weight gains and is especially critical when
washcloth), as appropriate. infant is 40 weeks after conception or more. Note:
Slow, sure movements provide stimulation while
reducing motor disorganization.
Provide pacifier/enable hand-to-mouth activity Nonnutritive sucking provides calming effect,
after feedings. decreases body movement, enhances sleep, and
increases weight gain.
Talk or quietly sing to infant, call infant by name, Provides auditory stimulation. Playing tape of
play soft music in nursery, or play a tape of parents’ voices may enhance infant’s recognition
parent(s) voice. of them.
Interact with infant at face level (en face Visual stimulation is best provided by objects
interaction), allowing eye contact. Provide colorful placed 7–9 in from face. Black and white faces and
linens and changing designs or pictures on side a checkerboard design promote visual attention.
of incubator, and encourage parents to make Infant may become habituated to stimuli that do
mobiles of construction paper and string once not change. Involving parents in creating stimuli
infant reaches postconception age of 40 wk. for infant helps ensure that the process continues
after discharge.
Hold infant in ventral position (e.g., baby held to Enhances visual stimulation/orientation.
shoulder to burp) when possible, uncover eyes
periodically if infant is receiving phototherapy.
Encourage periodic skin-to-skin contact, as Research suggest kangaroo-care technique not
appropriate (i.e., mother holds diaper-clad only provides closeness, strengthening mother-
infant upright between her bare breasts). infant attachment, but also reduces periodic
breathing and promotes deep sleep.
Assess infant for physiological signs/behavioral Disorganization of the autonomic system is often
cues indicating stress (e.g., apnea, color change, associated with prematurity, resulting in some
bradycardia, sneezing, yawning), irritability or infants lacking the developmental capability of
apathy, change in muscle tension, disorganized dealing with more than one sensory input at a
motor activity and sleep-wake cycles, measured time. Familiarity with the infant’s usual behavioral
change in sensory acuity), noting causative responses and personality traits is necessary for
factors and eliminating or reducing stressors identifying subtle changes that indicate stress
when possible. and the need for intervention to modify causative
factors.
Plan activities to allow periods of sleep. Prevent Helps protect infant from overstimulation, which
loud noises, limit conversation near bedside, can negatively affect growth and physiological
respond to alarms quickly; and reduce light status; promotes infant’s sense of the day-night
intermittently by covering incubator with towel, cycle. Note: Research reveals cycled lighting
shielding infant’s eyes, or lowering room lighting. lowers infant’s heart rate and motor activity,
promoting longer periods of quiet inactivity
resembling quiet sleep, and conserving energy.
Weigh infant daily. Note feeding frequency and Vagal stimulation produced by appropriate tactile
intake and frequency of stools. and kinesthetic stimulation promotes weight gain,
increases peristalsis and expulsion of waste products,
reduces gastric retention, and increases feeding
activity.
Note risk factors of birth weight, coexisting Retinopathy of prematurity is no longer believed
conditions, and associated therapies. to be exclusively the result of prolonged/high levels
of oxygen therapy. Immaturity, presence of some
congenital anomalies, and various therapies place the
infant at risk. Note: Infants with birth weight <1000 g
have an 88% incidence of retinopathy.
Provide parents with information about infant’s Parents must gain skill in recognizing subtle infant
behavioral cues and responses to stressors. (Refer cues indicating stress so that they can effectively
to CP: The Parents of a Child With Special Needs; intervene to minimize stress and facilitate the
ND: Parent/Infant Attachment, risk for altered.) infant’s positive adaptation to extrauterine life.
Awareness that visually impaired infant may not
show recognition or feelings by changes in facial
expression encourages parent(s) to observe body
language/other cues reflecting self-expression,
thereby strengthening the attachment bond.

Collaborative
Provide rocking or water beds, if indicated. Kinesthetic stimulation in preterm infants of 34
weeks’ gestation has been shown to improve sleep,
decrease heart rate, reduce frequency of state
changes, and increase head size and biparietal
diameter.

NURSING DIAGNOSIS: INJURY, risk for CNS damage

Risk Factors May Include: Tissue hypoxia, altered clotting factors, metabolic imbalances
(hypoglycemia, electrolyte shifts, elevated bilirubin)
Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual
diagnosis]
DESIRED OUTCOMES/EVALUATION Be free of seizures and signs of CNS impairment.
CRITERIA—NEONATE WILL:
Maintain homeostasis, as evidenced by ABGs; serum glucose,
electrolytes, and bilirubin levels WNL.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Assess respiratory effort. Note presence of Respiratory distress and hypoxia affect cerebral
pallor or cyanosis. function and may damage or weaken walls of
cerebral blood vessels, increasing risk of rupture. If
untreated, hypoxia may result in permanent damage.
(Refer to ND: Gas Exchange, impaired.)
Monitor Dextrostix levels, and observe infant Because of its demands for glucose, the brain may
for behaviors indicating hypocalcemia or suffer irreparable damage when serum glucose
hypoglycemia (such as convulsions, twitching, levels are lower than 30–40 mg/dl. Hypocalcemia
myoclonic jerks, or eye rolling.) (Refer to ND: (serum calcium levels 7 mg/dl) often
Nutrition: altered, risk for less than body accompanies hypoglycemia and may result in
requirements.) apnea and seizures.
Observe infant for alterations in CNS function, Birth trauma, fragile capillaries, and impaired
as manifested by behavior changes, lethargy, coagulation processes place preterm infant at risk
hypotonia, bulging or tense fontanel, eye rolling, for IVH, especially those infants weighing
or seizure activity. Investigate deteriorating 1500 g or under 34 weeks’ gestation. Tense or
status indicated by high-pitched cry, labored bulging anterior fontanel may be first sign of IVH,
respirations, and cyanosis, followed by apnea, hemorrhagic shock, or increased intracranial
flaccid quadriparesis, unresponsiveness, pressure (IICP), which can easily lead to death
hypotension, tonic posturing, and areflexia. from circulatory collapse. Infant of 32 weeks’
gestation may become lethargic or hypotonic and
may manifest uncontrolled “roving-eye” movements
and lack of visual tracking. Note: Clinical signs of
developing IVH may be absent, very subtle, or
sudden and life-threatening.
Measure head circumference, as indicated. Helps detect possible IICP or hydrocephalus, which
may be a sequela of subdural hemorrhage. Only
35%–50% of infants with hydrocephalus develop
normally.
Assess skin color, noting evidence of increasing Preterm infant is more susceptible to kernicterus at
jaundice associated with behavior changes such lower serum bilirubin levels than full-term infant
as lethargy, hyperreflexia, convulsions, and because of increased levels of unconjugated
opisthotonos. (Refer to CP: Newborn: circulating bilirubin crossing the blood-brain
Hyperbilirubinemia.) barrier.

Collaborative
Monitor laboratory studies, as indicated:
Hb/Hct; ABGs; Lowered Hb levels or anemia reduce oxygen-
carrying capacity, increasing risk of permanent CNS
damage associated with hypoxemia. Abrupt fall in
Hct may be first indicator of IVH. Note: Pulse
oximetry may be used to monitor O2 level routinely
with periodic ABGs to monitor other parameters of
acid/base balance.
Bilirubin levels. Rapidly rising levels may result in kernicterus if not
treated promptly.

Provide supplemental oxygen. Hypoxemia increases the risk of impairment or

permanent CNS damage.

Assist with diagnostic or therapeutic procedures,

as indicated:

Computerized tomography (CT) scanning, Identifies presence/extent of hemorrhage, which is

cranial ultrasonography; useful in predicting likelihood of long-term
complications and in choice of treatment.
Lumbar puncture; A bloody CSF specimen confirms IVH. Some
hospitals carry out serial daily lumbar punctures to
reduce ICP and prevent deleterious effects of
hydrocephalus.
 Exchange transfusion; Elevated or rapidly rising bilirubin levels indicate the
need for a double-volume exchange transfusion with
O-negative blood to remove bilirubin and to prevent
further hemolysis of RBCs.
Ventriculopuncture or taps; May be used to remove excess blood from the
ventricles, although studies have not indicated any
corresponding improvement in outcome.
Placement of ventriculoperitoneal shunt. Progressive ventricular dilation unresponsive to
other measures may require surgical intervention to
correct or prevent hydrocephalus.

Administer medications, as indicated:

Calcium, magnesium, sodium bicarbonate, Correction of imbalances helps prevent neonatal
and/or glucose; seizure activity, which may occur in response to
transient metabolic imbalances.
Phenobarbital; Helps to control acute convulsions and status
epilepticus in newborn.
Phenytoin or diazepam (Valium); May be used if other antiepileptic drugs are not
successful in controlling seizure activity. Note:
Dosage should be based on blood levels.
Furosemide (Lasix), acetazolamide (Diamox), Helps reduce intracranial pressure and treats
or steroids; secondary effects of bleeding.
Vitamin E; Antioxidant property protects RBC membranes
against hemolysis.
Indomethacin (Indacin). IV administration may correct hemodynamic
imbalances through closure of PDA.

Assist with fluid replacement or maintain Cerebral perfusion depends on adequate

restrictions, as appropriate. circulatory volume. Note: Fluids may need to be
restricted in cases of hypertonicity, CNS damage with
bleeding, or cerebral palsy.

Perform/obtain results of car-seat test prior Car-seat test is performed by nursing staff or
to discharge. occupational therapist (OT) on infant <2500 g or 37
weeks’ gestation. Infant is placed in car seat for 2 hr.
During that time, infant is monitored for possible
apnea, bradycardia, or oxygen desaturation. Infant is
surrounded by precut foam forms or rolled receiving
blankets to keep the head in a neutral, upright
position.

NURSING DIAGNOSIS: INFECTION, risk for

Risk Factors May Include: Immature immune response, fragile skin, trauma-tized tissues,
invasive procedures, environmental exposure (PROM, transplacental
exposure)
Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual
diagnosis]
DESIRED OUTCOMES/EVALUATION Be free of signs of infection, for example,
CRITERIA—NEONATE WILL: temperature instability, lethargy, respiratory
distress, purulent drainage/secretions.
Maintain negative serum, CSF, urine, and nasopharyngeal cultures
with CBC, platelets, and pH level WNL.
ACTIONS/INTERVENTIONS RATIONALE

Independent
Review record of delivery to determine whether Infant who has been resuscitated and has required
resuscitative measures were required, length of invasive interventions is especially prone to
rupture of membranes, and presence of introduction of pathogens and infection. Maternal
chorioamnionitis. Note maternal GBS status and/ factors such as PROM with preterm labor and
or other sexually transmitted diseases delivery possibly caused by an infectious process
(STDs) present. predispose the preterm infant to ascending infection.
Early-onset sepsis (occurring within the first 2 days
of life) is affected by host defenses and duration
of antepartal rupture of membranes. Transplacentally
acquired infections (which affect two-thirds of all
infected infants) are also a threat.

Determine gestational age of fetus, using Delivery prior to 28–30 weeks’ gestation increases
Dubowitz criteria. infant’s susceptibility to infection, because of reduced
ability of WBCs to destroy bacteria, reduced transfer
of IgG (IgG is transported across the placenta
primarily in the third trimester), lack of IgA if infant
does not receive breast milk, and poorly keratinized
skin with ineffective barrier qualities. Note: Infant
who suffers from intrauterine growth
retardation/restriction is at greater risk for infection.

Promote meticulous hand washing by staff, Hand washing is the most important practice for
parents, and ancillary workers per protocol. preventing cross-contamination and controlling
Use antiseptic before assisting with surgical or infection in the nursery.
invasive procedure.

Monitor staff and visitors for presence of skin Transmission of disease to neonate by employees
lesions, draining wounds, acute respiratory or visitors can occur directly or indirectly.
infections, fever, gastroenteritis, active
herpes simplex (oral, genital, or paronychial),
and herpes zoster.

Provide adequate space between infants or between Providing 4–6 ft of space between infants helps
Isolettes or individual units. Use separate isolation prevent spread of droplet or airborne infections.
rooms and isolation technique, as indicated.
Assess infant for signs of infection, such as Useful in the diagnosis of infection; body
temperature instability (hypothermia or temperature alone is an unreliable means of
hyperthermia), lethargy or behavior changes, assessing infection in the preterm infant with
respiratory distress (apnea, cyanosis, or impaired inflammatory response and WBC
tachypnea), jaundice, petechiae, nasal mobilization.
congestion, or drainage from eyes or umbilicus.
Establish a cohort of infants, when possible, and Infants who are born within the same time frame
ensure that same nurse cares for the infants (usually 24–48 hr), or who are colonized/infected
grouped together. with the same pathogen, may be grouped together
until discharge. Such grouping is an important
measure in infection control in that it limits the
amount of contact of one infant with other
susceptible infants or personnel.
Perform care of umbilical cord according to Local application of alcohol, triple dye, or various
hospital protocol. antimicrobials helps prevent colonization.
Prepare site(s) of invasive procedures with alcohol Reduces incidence of possible phlebitis or
(70%), tincture of iodine, or iodophor. Monitor IV bacteremia.
infusion site(s) and sites of invasive monitoring
lines per protocol.
Use aseptic technique during suctioning. Date the Reduces opportunity for introduction of bacteria
opened solution for humidification, irrigation, or that could result in respiratory infection.
nebulization, and discard after 24 hr. Ensure
routine cleaning or replacement of respiratory
equipment.
Treat arterial line, stopcocks, and catheter as sterile Helps prevent bacteriemia associated with arterial
fields; draw all blood specimens at the same time, line and its direct access to blood and deep tissues.
when possible.
Monitor infant for signs of late-onset disease Late-onset disease may occur as early as the 5th
or infection. day, but usually occurs after the 1st wk of life. Signs
of late-onset infection are likely to be caused by
bacteria acquired from the maternal genital tract, or
from human contact or contaminated
equipment/supplies after birth.
Observe for signs of shock or DIC, such as DIC may occur with gram-negative septicemia.
bradycardia, decreasing BP, temperature
instability, listlessness, edema, or erythema of
abdominal wall.
Provide breast milk for feeding, if available. Breast milk contains IgA, macrophages, lymphocytes,
and neutrophils, which provide some protection
from infection.

Collaborative
Obtain specimens as indicated (e.g., urine through Cultures/sensitivity tests are necessary to
suprapubic aspiration, blood, CSF, visible skin diagnose pathogens and identify appropriate
lesions, nasopharynx, or sputum, if infant is therapy.
intubated).
Monitor laboratory studies, as indicated:
Serial WBC count and differential; Prematurity reduces the immune response to
infection. WBC count in preterm infant varies from
6000 to 225,000/mm3 and may change from day to
day, limiting diagnostic reliability. A marked and
sudden increase or decrease in WBCs or band cells
may suggest infection.
Platelet count; Sepsis causes platelet count to drop, but in the
preterm infant, the normal platelet range may be
60,000 (in the first 3 days) to 100,000/mm3.
Serum glucose and pH levels. Hypoglycemia, hyperglycemia, or metabolic acidosis
(with bicarbonate levels <21 mEq/L) suggests
infection.
Administer antibiotics IV based on results of Broad-spectrum antibiotic coverage with
culture and sensitivity. ampicillin and an aminoglycoside is usually initiated,
pending results of culture and sensitivity tests.
Indiscriminate or inappropriate use of systemic
antibiotics may cause undesirable side effects, foster
emergence of resistant bacterial strains, and alter the
newborn’s normal flora.
Monitor drug levels, especially if infant is receiving Kidney immaturity inhibits or retards drug
gentamicin or nafcillin. excretion, so that in the preterm infant, toxicity can
occur more quickly and at lower levels than in the
full-term infant.

Assure proper amount and concentration of Human milk contains less renal solute than does
supplemental formula. cow’s milk. Kidney may be unable to handle formula
with excess concentration of solute.

Assist with lumbar puncture, as needed. Helps identify organism and site of infection when
meningitis is suspected.

Assist with treatment for possible conditions Associated physiological events and sequelae may
associated with infection, for example, hypoxemia, be as life-threatening to the infant as the infection
thermal abnormalities, electrolyte and acid-base itself.
imbalances, anemia, or shock.

Administer IV Ig as appropriate. Research suggests IV administration of Ig may

increase survival rates in septic infants. In addition,
prophylactic therapy for infants weighing <1500 g
may reduce incidence of late-onset nosocomial
infections.

NURSING DIAGNOSIS: CONSTIPATION/DIARRHEA, risk for

Risk Factors May Include: Dietary/fluid intake, physical inactivity, weak abdominal
musculature, altered gastric motility
Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual
diagnosis]
DESIRED OUTCOMES/EVALUATION Establish customary bowel habits, dependent on
CRITERIA—NEONATE WILL: type of feeding, with abdomen soft and nondistended.
Be free of signs of NEC and Clostridium difficile organism.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Consider frequency and characteristics of stool Decreased bowel functioning and GI motility
in relation to infant’s age and type of feeding. result in infrequent stools and abdominal
Auscultate bowel sounds. Measure abdominal distension.
girth, reporting any increase of 1 cm or more
from previous measurement.
Note presence of risk factors, such as hypoxia, These conditions can contribute to development of
sepsis, or circulatory problems associated with NEC. Recent findings suggest that the development
PDA. (Refer to NDs: Gas Exchange, impaired; of NEC is related to developmental and
Infection, risk for.) gestational age.
Assess hydration status and fluid intake and Inadequate hydration may contribute to dry or
output. (Refer to NDs: Fluid Volume risk for constipated stool.
deficit; Nutrition: altered, risk for less than
body requirements.)
Monitor for signs of NEC, such as abdominal NEC is a potentially life threatening complication
distension, rigidity, or tenderness; shiny or that affects 3%–8% of preterm infants, usually
taut abdominal skin; visible bowel loops; presenting within the first 2 wk of life.
excessive spitting up, bile-stained emesis; failure
of gavage feedings to be absorbed or excessive
gastric residual; and absence of bowel sounds.
Test stools (unless bloody diarrhea is present)
using Hematest or guaiac. Test gastric residual.
Minimize handling of infant; provide stroking of Avoids further abdominal trauma. Emotional and
face, hands, and feet. Talk to infant. stroking needs can be met through touching
extremities and head and through quiet conversation.
Monitor for signs of C. difficile. Initiate/maintain Increased foul-smelling stools, thick green to tan
contact precautions if detected by culture (use of color and texture suggest the presence of C. difficile
gloves/gown). organism. Associated cramping is manifested by
infant’s bringing knees to abdomen and crying.
Discomfort may be noted by scowl on face and mild,
continuous, moaning cry.
Avoid use of diapers and rectal thermometers. Diapers increase lower abdominal pressure and
prevent or restrict observation of abdomen. Rectal
thermometers may cause trauma to rectal mucosa.
Monitor infant for signs of sepsis, shock, or DIC NEC can progress to bowel perforation with
(e.g., bradycardia, decreasing BP, temperature peritonitis, resulting in sepsis, shock, and DIC.
instability, listlessness, and edema or erythema
of abdominal wall).

Maintain strict policy of hand washing before/ Helps prevent an epidemic of NEC from occurring
after handling each infant. in the nursery.

Collaborative
Use breast milk for feedings whenever possible. Breast milk is more easily digested, produces softer
stool, and may reduce risk of enteric infections or
development of NEC.
Increase dilution of supplemental formula Diarrhea may indicate intolerance to formula
as indicated. concentration.
Monitor laboratory studies, as indicated, e.g., Increased or decreased WBC count or a shift to the
WBC count and differential, platelet count, left suggests sepsis. Thrombocytopenia or prolonged
PT, and PTT. clotting times may indicate developing DIC.
Review abdominal x-rays. Presence of distended loops of bowel, thickened
walls, and ascites reflects NEC.
Send initial bloody or positive Hematest stool to Alum-precipitated toxoid test is required to
the laboratory. differentiate infant from maternal blood.
Discontinue oral or gavage feedings for 7–10 days, Allows the bowel to rest, promoting tissue healing
as indicated. Provide TPN feedings. while meeting fluid and nutritional needs.
Insert orogastric or NG tube, and connect to May be necessary for gastric decompression in
continuous, low suction, as needed. cases of suspected NEC or following surgical
intervention.
Administer antibiotics, such as vancomycin, May be given IV or PO to combat enteric infection.
as indicated. May promote healing of bowel.
Prepare for surgery, as appropriate. Operative procedure may be necessary to remove
segments of inflamed bowel.

NURSING DIAGNOSIS: SKIN INTEGRITY, risk for impaired

Risk Factors May Include: Thin skin, fragile capillaries near the skin surface, absence of
subcutaneous fat over bony prominences, inability to change
positions to relieve pressure points, use of restraints (protecting
invasive lines/tubes), alterations in nutritional state
Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual
diagnosis]
DESIRED OUTCOMES/EVALUATION Maintain intact skin.
CRITERIA—NEONATE WILL:
Be free of dermal injury.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Inspect skin, noting areas of redness or pressure. Identifies areas of potential dermal breakdown,
which can result in sepsis. (Refer to ND: Infection,
risk for.)
Provide mouth care using saline or glycerin swabs. Helps prevent drying and cracking of lips
Apply petroleum jelly to lips. associated with absence of oral intake or the drying
effects of oxygen therapy.
Avoid application of harsh topical agents; Helps prevent skin breakdown and loss of
carefully wash off povidone-iodine solutions protective epidermal barrier.
after procedures.
Provide range-of-motion exercises, routine Helps prevent possible necrosis related to edema
position changes, and fleece or flotation pad. of dermis or lack of subcutaneous fat over bony
prominences.
Minimize use of tape to secure tubes, electrodes, Removal of tape may accidentally remove
urine bags, IV lines, and so forth. epidermal layer, because cohesion is stronger
between tape and stratum corneum than between
dermis and epidermis.
Bathe infant using sterile water and mild soap. After 4 days, skin develops some bactericidal
Wash only grossly soiled body parts. Minimize properties because of acid pH. Frequent bathing
manipulation of infant’s skin. using alkaline soaps or moisturizers may raise skin
pH, compromising normal flora and natural defense
mechanisms that protect against invading pathogens.
Change electrodes only when necessary. Frequent changing may contribute to skin
irritation/dermal injury.
Collaborative
Apply antibiotic ointment to nares, mouth, and lips Promotes healing of lesions associated with
if they are cracked or irritated. administration of oxygen; reduces risk of infection.