NURSING CARE PLAN

1. Patient Bio-Data

 Name - Baby of Mannu

 Age - 27 day
 Sex - Female
 Religion - Hindu
 Father’s name - Mr. Sumit Kumar
 Occupation - Farmer
 Education - 5th
 Mother’s name - Mrs. Mannu
 Occupation - House wife
 Education - Nil
 Date of admission - 12/11/2019
 Informant - mother
 Diagnosis - ELBW with RDS
 Surgery (if any) - No
 Paediatrician - Dr . S .K.sanewar (M.D.)

2. Presenting complaints (complaints given by mother)-: patient is admitted in the hospital with the complain of;

1. Difficulty in breathing since birth

2. Unable to feed properly
3. Grunting since birth
4. Unable to maintain body temperature

2. History of present illness:

 The baby was admitted in the NICU on 12/11/19 with the complaints of difficulty in breathing, unable to feed, grunting and
unable to maintain body temperature since birth. After history taking, physical assessment and investigations, the baby is
diagnosed as case of ELBW with RDS.

a) Therapy /treatment received so far:

S.no Drug name Dose Route Frequency Action

.
1. Inj. Piptaz 0.6 ml IV TDS Antibiotic
2. Inj. Gentamycin 0.1ml IV OD Antibiotic
3. Inj. capnea 0.9 ml IV OD Smooth muscle relaxant,
CNS stimulant, cardiac
muscle stimulant
4. Syp. Calcimax 2.5 ml Oral BD Calcium supplements
5. Drop Zinocivit 8 drops Oral BD Multivitamin supplements
6. Syp. Ibugesic 0.5 ml Oral OD Antibiotic

4. Past history: there is no significance of past medical or surgical history

5.Birth history

a. Antenatal history
-mother taking adequate nutrition at the time of pregnancy: yes
-registered in the health facility: yes
-consuming iron and folic acid: yes
-regular antenatal checkups: yes (total 3 antenatal visits has been attended by mother)

b. Natal history

 Type of delivery: normal vaginal delivery

 Baby cried/ not cried at birth- yes baby cried soon after birth
 Instrumental delivery (where)- no
  weight of the child – 900 gm

c. Postnatal history

-Condition of the baby: baby was having difficulty in breathing, grunting, ELBW

-history of any infections (PPH or any other problems): Not present

6. Personal History

A) Personal hygiene of the child – Personal hygiene of the child is maintained by mother and health care worker.
B) Response of child towards illness – The baby is very irritable and looks anxious .
C) Response of parents to child’s illness – worried about their baby’s condition.

7.Developmental history: use the growth and development format as per the age

8. Family history:

- History of contact illness (TB/HIV): No

- History of similar ailment in the family: Not present
- History of consanguinity: no
- Birth order: second
- Number of siblings: none
- Illness: Other family members are healthy
- Any death in the family: Grandfather of Mr. Sumit has died 2 years ago.

9. Socio-economic history:

-nuclear/joint family: Nuclear family

-Who look after child – the mother and health workers looks after the child
 -Housing condition: Semi pucca

-Overcrowding: Not present

-rural/urban: Rural

-Water source (drinking): Hand pump

-smoking among family members: Father

-Schooling of the child: Not

10. Nutritional history:

- Breastfeed/top feeds/mixed mode of feeding: expressed breast milk is given to the child by tube feeding frequently

11. Immunization : Baby has immunized at proper time . She get all doses of immunization per schedule till now.

Any known allergies- no

Blood transfusion till date (if any): not

PHYSICAL EXAMINATION

1. General examination:
 General condition: poor ,
 Decubitus- not present
 Built & nutrition (PEM Grade)calculated by degree of malnutrition formula= actual weight/ expected weight*100
 Pallor - Not present
 Icterus- Not present
 Cynosis- Not present
 Edema- absent
 Clubbing of nails- Not present
 VITAL SIGNS

Temperature - 36° C
Pulse - 140 beats/ min
Respiratory rate – 72 breaths/ min
Blood pressure -110/90 mm. hg
Oxygen saturation – 92%

Anthropometric measurement:

Height /length : 36 cm

Weight : 900 gram

Head circumference : 26cm

Chest circumference: 21 cm

Abdominal circumference : 22 cm

Mid upper arm circumference: 6 cm

Condition of skin: petechiae, redness, bruises (special areas), scratches, blunt injury, open wound are absent in the baby.

Head: head circumference is less than normal new born baby

Condition of hairs:

a. Color - Black
b. Flag signs- absent
c. Dryness- absent
d. Pediculosis - absent
 e. Dandruff - absent
f. Split ends- not present

Head shape: round

Fontanelles: not closed

Cranial sutures: Normal

Characteristics of faces:

Eyes: no redness or discharge present

Ear: the pinna of the ear are delayed recoiled

Neck: trachea is midline.

Condition of nails: color is pinkish

Head & face: small face

2. Systematic circumference

a. Respiratory system
Respiratory rate - 45breath/ min
Use of accessory muscles- yes
Type of breathing - presence of voice during breathing
Movement/ symmetry -symmetry
Chest wall deformity - absent
Neck vein distension - absent
Trachea midline - normal
Air entry - not clear
Any other audible sounds- grunting
b. Cardiovascular system
Apex beat -45beat/min
Any murmur - not present
Any other sounds - not present

c. Abdomen
 Shape - cylindrical
 Prominent veins - absent
 Visible peristalsis - Not present
 Bowel sounds audible - Not clear
 Distension - absent
 Abdominal wall rigidity/ guarding – Present
d. Musculoskeletal
 Joints: range of motion of joints is limited because the baby is very week

e. Gastro nervous system:

Stool color and character : Normal
Diarrhea : absent
Constipation : Not present
Vomiting : Not present
Hematemesis : Not present
Jaundice : Not present
Abdominal pain : absent
Colic : Absent
Appetite : Absent

f. Central nervous system

 Appearance - the baby looks dull
Posture - extended arms
Gait - unable to walk
State of sensorium – baby is orient
Meningeal irritation -Not present
Abnormal movements - Not present
Sensory -sensation to touch and pain is present

GROWTH & DEVELOPMENT ASSESSMENT

Neuromascular system

Cry – weak cry present in the baby

Flexion of extremities- present

Extension of extremities – present

Heads lags while sitting- present

Turn head from side to side- present

Signs of paralysis _ absent

 Head lags in all position- present

Myoclomic jerks_ absent

Reflexes :-

Eyes- Blinking and papillary reflex present

Nose – sneeze reflex present

Mouth and throat – poor sucking reflex present , weak gag and rooting reflexes present

Extremities – weak palmar and plantar reflex present

Mass reflexes- moro and startle reflex present , stepping or dancing reflex is absent, weak asymmetric tonic neck reflex present

INVESTIGATIONS

Routine investigation:

s. Investigations Patient value Normal Remarks

no. value

1. Complete blood count

Haemoglobin 18.4 g/dl 14-22
Total lecocyte count(TLC) 24500 cells/mm3 10000-26000 Increased
2. Differential./. leucocyte count 77% 55-65
Neutrophils 20% 25-35
Lymphocytes 02% 1-6 Increased
Esinophills 01% 1.0-5.0
Monocyte 00% 0.0-2.0
 Basophills 1.80 lac cells/mm3 1.5-4.5
Platelet counts 9.2 ft 7.4-10.4
MPV 5 million cells/ml 5-7
Total RBCs 107.3 ft 100-120
MCV (mean cell volume) 36.7 pg 31-37
MCH(mean corpus. Haemoglobin) 34.2 g/dl 30-35
MCHC(mean corpus. Hb. Conc.) 20.4% 11.5-14.5
RDW 53.7% 45-75
HCT(hematocrit)
BIOCHEMISTRY
KIDNEY PANEL 34.6 mg/dl 10-45
Serum urea 0.74 mg/dl 0.6-1.5
Serum creatinine
ELECTROLYTE 130.7 mg/dl 135-145
Serum sodium 4.98 mmol/l 3.5-5.3
Serum potassium 4.16 mg/dl 4.5-5.5
Serum ionic calcium
C-REACTIVE PROTEIN 1.16 mg/L 0-6
CRP
Special investigations: MRI/ CT Scan/Biopsy/FNAC/CSF/Histo pathological has not done

NURSING DIAGNOSIS

 Imbalanced nutrition less than body requirements related to weak reflexes as evidenced by poor sucking of baby.

 Ineffective breathing pattern related to the immaturity of the respiratory center as evidenced by grunting of the baby and
respiratory rate of the baby

 Risk for infection related to ineffective immunological defense as evidenced by lab reports of baby

 Risk for Ineffective thermoregulation related to Immature CNS and subcutaneous fat loss as evidenced by less body
temperature of baby
 Risk for fluid volume deficit related to age and weight extremes and excessive fluid loss (thin skin) as evidenced by skin turgor
of baby.

 Risk for impaired growth and development related to premature birth as evidenced by less anthropometric measurement of
baby

 Anxiety of parents related to baby’s disease conditions as evidenced by facial expression of parents

s. Assessment Nursing Goal Implementation Rationale Evaluation

no diagnosis
.
1. Subjective data- Imbalanced To maintain Assessd maturity reflex, with Determine the After 24 hours
nutrition less the regard to feeding (eg, appropriate method of of the nursing
Pateint’s mother says than body nutritional sucking, swallowing, and feeding for infants. intervention
that her baby is not requirements status of the cough). the patient was
feed properly related to baby To check peristaltic able to meet
weak reflexes Auscultated for presence of movement of the baby the goal
as evidenced bowel sounds. partialy .
by poor To know the (Maintain
sucking of Assess the weight of the baby fluctuations in weight growth and
baby every day and documented in of the baby weight gain in
file. a normal
Provide information curve)
Objective data: Monitor the intake and output about the bowel
The baby is enable to every day. pattern
suck the breast of the
mother Monitored laboratory tests as To check the state of
indicated: blood glucose level hypoglycemia

Measured the abdominal girth To know the

of the baby everyday abdominal distension

Provided expressed breast To fulfill the

milk of the mother by NG nutritional
tube requirement of baby

Provided KMC to the baby by

mother frequently To gain the weight of
the baby

s. Assessment Nursing Goal Implementation Rationale Evaluation

no diagnosis
.
2. Subjective data: Ineffective After the 24 Help in distinguishing The Neonate
Assess the cardiac frequency
The mothr of the baby breathing hours of normal breathing and maintains
and pattern of breathing,
complaints that the pattern nursing apnea periodic
baby is not breathing related to the intervention breathing
properly immaturity of , the normal Suction the airway as needed. Eliminate mucus that patterns.
the breathing clogs the airways.
respiratory pattern of Place the baby in the
center as the baby abdomen or supine position This position
evidenced by will with a rolled diaper under the facilitates breathing
grunting of establish shoulder to produce and decrease
the baby and hyperextension. episodes of apnea
respiratory
Objective data: rate of the
The baby looks baby Review the history of the Magnesium sulfate
restless and mother to drugs and narcotics suppress
respiratory rate is 72 the respiratory center
breaths/min and CNS activity.
Improvement of
Provided oxygen as indicated. oxygen and carbon
dioxide levels can
improve respiratory
function.

Checked the vital signs of the To know the

baby i.e. temp-36°c. HR-140 fluctuations in vital
beats/min, R-46 breaths/min, parameters
Spo2-92%
Provided medications as To helps in the lungs
indicated maturity

s. Assessment Nursing Goal Implementation Rationale Evaluation

no diagnosis
.
3. Subjective data- Risk for To prevent Assess for signs of infection To find early signs of Partially meet
baby’s mother says infection infection infection the goal
that the baby is having related to into the Leukocytes
some redness on the ineffective baby Actions taken to 5000-10000.
body immunolo Done hand washing before minimize the occurrence
gical and after handling the baby of infection wider.
defense as
Objective data- evidenced
I observed that ; the by lab
baby has developing reports of Make sure all equipment is To prevent infection.
some rashes on the baby in contact with the baby
body (TLC 12000 clean and sterile
cells/mm3)
Educated the mother about To prevent infection
importance of hand washing from the mother
and maintenance of personal
hygiene

Administered antibiotic To reduced the sign of

drug as per as doctor’s order infection

Checked the lab report of Helps to know presence

the baby of infection by
leucocytes count

s. Assessment Nursing Goal Implementation Rationale Evaluation

no. diagnosis
4. Subjective data- After the Checked the vital signs of To know the fluctuations
Risk for nursing the baby in temperature The baby
Patient’s mother Ineffective intervention maintains the
complaint that the thermoreg Kept the baby in the radiant normal
the baby
baby ‘ s body is cool ulation temperature
will warmer
related to : To prevent hypothermia after the 6-8
Immature maintain hours of
CNS and normal Provided kangaroo mother nursing
subcutane body care to the baby by mother Helps to maintain the intervention
ous fat temperature temperature by skin to
loss Warmed the hand before skin contact of mother
touching the baby and baby
Objective data-
After checking the Covered the baby in the
temperature, the cloth properly (nesting) To maintain the
temperature is 35°c thermoregulation of the
baby
 

To protect from heat loss

s. Assessment Nursing Goal Implementation Rationale Evaluation
no. diagnosis
5. Subjective data: Risk for To maintain Monitored the weight of the To know the hydration The hydration
fluid the baby daily status of the baby status of the
Patient’s mother volume hydration baby
complaint that the deficit Maintained intake and Helps to determine the maintained
status of the
baby is having related to output chart of the baby need of fluid requirement partially
dryness on the skin age and baby
weight Monitor the vital signs of Helps to know the signs
extremes the baby of shock
and
excessive Evaluate the skin turgor, Helps to know the status
fluid loss mucus membrane and status of dehydration
Objective data: as of anterior fontanelles
evidenced
I also observed that by skin Helps to know the
patient get tired turgor of Assess the IV site every infiltration of fluid,
easily whenever he baby hour swelling
become active.
Tachycardia is also Provided IV fluid to the To prevent dehydration
present at that baby according to age and
moment in patient. weight of the baby

s. Assessment Nursing Goal Implementation Rationale Evaluation

no. diagnosis
6. Subjective data: Anxiety To reduced Recognized the parent’s To identify the needs of The parents
of parents the anxiety level of fear and anxiety the parents anxiety level is
Baby ’s mother says related to level of the reduced
that she is worried baby’s baby Orient the mother about the partially
about her baby disease Helps to decrease the
environment and
conditions anxiety level of parents
as equipments using on the
evidenced baby
Objective data: by facial
I observed that the expressio
mother looks n of
anxious about her parents Identified the needs of the Helps to prioritize their
baby parents of the baby need

Clarified their doubts about

Helps to understand
their baby’s condition parents about the
problems of the baby

Provided psychological To decrease the anxiety

support to the mother level
HEALTH EDUCATION

Breastfeeding

 Educated the mother about the advantages of breastfeeding, importance and its effect on the baby’s weight gain.
 Educated the mother about the various techniques of breastfeeding and latching of the baby’s mouth.
 Asked the mother to take healthy and nutritious diet to fulfill the feeding requirement of the baby.
 Educated the mother about the expressed breast milk and its storage and methods of feeding the baby by katori and spoon.
 Educated the mother about importance of colostrums and burping of the baby after feed the baby to prevent backflow of milk.

Kangaroo mother care

 Educated the mother about the benefits of KMC for the baby such as weight gain of baby, maintenance of temperature and
adequate growth and development of baby.
 Educated the mother about the initiation and procedure of kangaroo mother care.

Immunization

 Educated the mother about the importance of vaccination to prevent the child from diseases.
 Asked the mother to vaccinate the baby according to the immunization schedule card of the baby.

Personal hygiene

 Asked the mother to maintain the personal hygiene of the baby as well as her.
 Educated the mother about maintenance of cleanliness of breast to prevent the baby from infection.
 Educated the mother about baby bath, changing the diaper, eye care, skin care etc.

Medication and follow-up

 Educated the mother about the importance of medication for the early recovery of the baby.
 Asked her to weight the baby periodically to know the progress of the baby even after discharge.
 Educated the mother about signs of complication to the baby occur, immediately go for the doctor.
PROGRESS NOTE

DAY- 1ST – The baby admitted in the NICU with the complaints of difficulty in breathing, grunting, unable to maintain normal
temperature and unable to feed. On admission the condition of the baby was serious. The baby was kept on the radiant warm and
ventilator after the insertion of ET tube and NG tube. IV fluids started immediately. Cardiac monitor attached with baby. The vital
signs of the baby were:-

Pulse rate- 150beats/ min

Temperature - 94.6 ° F

Respiration - 72breaths/min

Spo2- 60 %

To relieve patient we provide medication as prescribed by the doctor. After 2 hours of medication and nursing intervention patients
vital signs become normal

DAY-2nd - On the day second, the baby looks better from the previous days. The NG tube feeding is given to the baby by the
expressed breast milk of the mother. The iv fluid also given to the baby. The baby was on the oxygen therapy. The bowel and bladder
pattern of the baby was normal. The shoulder roll and head roll put under the shoulder and head of the baby to decrease the risk of
apnea. The inake and output of the baby was normal. The vital signs also checked

Vital signs:

Pulse 140beats/min

Temperature 36 c

Respiration 46breath/min

SPO2 92%
DAY-3rd – On the third day the baby looks better from the previous days, the baby gained some weight and there is no grunting or any
other breathing abnormality present. The baby’s intake and output is normal. The medication is given to the baby such as sy[p. capnea,
calcimax etc. The mother asked to provide kangaroo mother care to the baby. Daily weight recording has been done. The EBM was
given to the baby by NG tube feeding. The vital signs have been checked.

Vital signs:

Pulse 142beat/min

Temperature 97.2 F

Respiration 42 breath/min

Spo2 90%
 BIBLIOGRAPHY

 “Sharma Rimple, Essentials of Pediatric Nursing, First Edition, Jaypee Brothers Medical Publishers LTD, 2013,Page
No. 160-178”

 TM Beevi Assuma, Pediatric Nursing care Plans, First Edition, Jaypee Brothers Medical Publishers LTD, 2012,Page
No. 108-120

 “Dutta Parul, Pediatric Nursing, Third Edition, Jaypee Brothers Medical Publishers LTD,2014, Page No. 110-120”

 “Wongs, Essentials of Pediatric Nursing, Eighth Edition, Reed Elsevier India Private LTD,2012,Page NO.585-596”

 “Ghai OP, Essentials of Pediatric Nursing, Eighth Edition, CBS Publishers Private LTD, 2012, Page NO. 76-80”

 “Gupta Suraj, The Short Textbook Of Pediatric Nursing, Eleventh Edition, Jaypee Brothers Medical Publishers LTD,
2013,Page No. 114-118”