|Hello, I am Debra Neiman, RN BSN.
I have worked in Neonatal Care, at Beauregard Memorial Hospital, DeRidder for over four years. My college experience at Louisiana State University at Alexandria, resulted in a great deal of research papers, which are gathering dust in my office. My curriculum at Northwestern State University also added to this wealth of information.
I hereby begin this series to provide a way to get this information to those in the nursing field and any other person with a passing interest in these subjects.
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Orem's Self Care Model
Newborn Nursing Care Plan
Debra Neiman, RN, BSN, Spring 1995
Prepared for Nursing Professional Transition Practicum
Northwestern State University
I. Orem's Self Care Model
Dorothea Orem uses the four components of nursing care: person, health, environment, and nursing in her theory. Self-care is defined as the ability to interact with the environment to perform self care to maintain life, health, and well-being (Kelly, 1992). Whenever therapeutic self-care demands exceed self-care and dependent care ability, a self care deficit is created and nursing comes in to fill the gap (Polit & Hungler, 1993). These demands may be universal (food, air, water, warmth), health-deviation (illness, injury, stresses of change), or developmental (age, mobility, cognitive) in nature. Nurses provide support by acting for or doing for another; guiding another; supporting another; providing a supporting environment; teaching (Tolentino, 1990).
Neonates also have the potential for self care. They have signaling actions to call others to act on their behalf and fulfill their needs. Parents (Dependent Care Agents), know the motivation of a crying baby. Nurses can clue into neonates need to be left to rest by subtle self-pacifying behaviors such as nonnutritive sucking while sleeping. Apnea or bradycardia may be signals that the newborn is not tolerating a procedure (Tolentino, 1990).
Introduction of Client
36 week gestation, white, female newborn born 1-12-95 per vaginal delivery after failure to stop premature labor. Apgar 8/9. Resiscitation per positive pressure ventilation for 2 minutes and transferred to nursery under free oxygen per face mask. Admitted to nursery with special care nursery orders, medical diagnosis RDS and prematurity; weight 4 pounds 3 ounces (1458 grams). Mother is 32 years old, gravida 6 para 6, and experiencing complicated delivery requiring admission to surgical unit STAT.
Newborn is in respiratory distress, bilateral advantageous breath sounds (crackles), with deep intercostal retractions and substernal retractions. Acrocyanosis is noted, but newborn is centrally pink and active.
Oxyhood initiated at 40% FiO2, with should roll to maintain open airway position. Newborn is on radiatn warmer with temperature probe to abdomen, incubator set at 37.0C. Axillary temp 97.2F. Warmed and humidified oxygen being administered. Glucose per chemstrip is 65-80 mg/dl.
Respiratory, radiology and lab are notified for workup. Peripheral IV started in right hand with 24 guage insyte catheter, D10W infusing per IVAC/burretol at 6 ml/hr. Cardiac/apnea monitor and pulse oximeter monitoring began with regular sinus rhythm of 162, respiratory rate 75, and SaO2 96% while under oxygen support. Blood pressure 55/35. Capillary refill <2 sec, pulses strong and regular all extremities, newborn reflexes present and appropriate.
Oral gastric 5 french tube placed and checked by auscultation. Obtain 5cc clear mucous and 7cc air by aspiration and tube left open to air. CBG: CO2: 50, pH: 7.31, CXR: ground glass appearance, heart WNL, tube tip in stomach.
Lab values are obtained. CBC: WBC 22,000, HCT: 47.5, HbG: 15, platelets: 197, Bands: 22, Segs: 5, NRBC: 1. Glucose: 65, BUN: 4, Ca+: 8, cultures drawn. Administer 73mg Ampicillin and 3.6mg Gentamicin per IV push as ordered. Urine specimen obtained from pedi bag, UA: WNL, and Negative for Beta Strep. Continue to assess and monitor newborn as per Special Care Orders and Nursery Protocol.
The newborn has three universal self care deficits that take priority in the first few hours and are addressed in this paper. Also considered in a comprehensive care plan (not included in this paper) is the parents' role and their dependent care agent deficits.
1. IMPAIRED GAS EXCHANGE related to inadequate surfactant levels; as evidenced by grunting, flaring, substernal and intercostal retractions, CO2 50 and pH 7.31 per CBG and CXR with ground glass appearance suggestive of hyaline membrane disease.
2. INEFFECTIVE THERMOREGULATION related to prematurity and low birth weight; as evidenced by poor flexion and lack of subcutaneous fat stores needed for non shivering thermogenesis.
3. ALTERED NUTRITION: LESS THAN BODY REQUIREMENTS related to respiratory distress; as evidenced by confinement under oxyhood, oral gastric tube to drainage, respiratory rate greater than 60 per minute, and NPO status.
Based on the priority nursing diagnoses, the following expected outcomes are provided:
1. THE NEWBORN WILL HAVE IMPROVED GAS EXCHANGE, gradually weaned to room air and breathe normally without supplemental oxygen within 24 hours. (AEB: CBG - pH 7.35 to 7.45, CO2 40-50, CXR free from infiltrates and atelectasis, bilateral breath sounds clear and with equal and unlabored expansion of chest without grunting, flaring or retractions, color centrally pink, respiratory rate 40-60, and SaO2 per pulse oximetery 95-100%).
2. THE NEWBORN WILL MAINTAIN THERMAL HOMEOSTASIS, with axillary temperature 97.8 to 98.6 while requiring support of radiant warmer and/or incubator.
3. THE NEWBORN WILL MAINTAIN ADEQUATE HYDRATION, OUTPUT, AND GLUCOSE LEVELS while on IV support during first 24 hours. (AEB: good skin turgor, weight, urine output of 25-60 cc/day, serum glucose levels per chemstrip >65 mg.dl, active, responsive and without jitterness).
The nurse provides Wholly Compensatory and Partial Compensatory roles to assist the newborn achieve the established goals. The nurse acts for or does for another: by assessing, suctioning, chest physiotherapy, maintaining equipment and IV/medication support. The nurse also provides a supporting environment for the newborn to achieve homeostasis by feeding, bathing, maintaining neutral thermal environment, protecting from injury (Tolentino, 1990). These nursing interventions were implemented and accomplished per the care plan (Speer, 1990).
1. IMPAIRED GAS EXCHANGE:
- - Administered warmed and humidified oxygen at rate ordered per oxyhood, wean slowly to room air as ordered.
- - Monitor and document hourly Fi)2 levels per calibrated O2 analyzer. Sa)2 per pulse oximeter, and vital signs (temperature, heart rate/rhythm, respiratory rate and effort).
- - Auscultate lung fields hourly and assess respiratory effort hourly, cyanosis, grunting, flaring or retracting and activity.
- - Maintain gastric decompression per oral gastric tube open to air, perform oral/nasal suctioning and chest physiotherapy as ordered.
- - Maintain temperature in normal range and schedule nursing interventions to help newborn minimize stress, conserve energy, and reduce oxygen requirements.
- - Assess hourly for continued improvement and readiness to wean from oxygen therapy, as well as, signs of worsening condition.
2. INEFFECTIVE THERMOREGULATION:
- - Provide neutral thermal environment per radiant warmer with temperature probe secure and in anterior position to newborn.
- - Protect newborn from loss of body heat from conduction, convection, radiation, and evaporation.
- - Cover warmer bed over infant's chest and lower body with saran wrap to prevent insensible fluid loss and drafts.
- - Monitor axillary temperature hourly and adjust settings on warmer as needed to maintain temperature of 97.8 to 98.8 F.
- - Warm and humidify oxygen being delivered to newborn.
3. ALTERED NUTRITION:
- - Provide IV fluids, D10W for hydration and glucose while newborn is under oxyhood.
- - Assess need for parenteral nutrition if oxygen therapy is longer than 12 hours.
- - When respiratory status has stabilized begin feeding newborn D5W to assess tolerance to oral feedings. Begin formula feedings after two glucose water feedings.
- - If newborn does not have a strong sucking, gag, or swallow reflex or is at risk for aspiration, provide feedings through a nasogastric (NG) tube.
- - Monitor glucose levels hourly until stable, each four hours times two, then every eight hours while on IV fluids.
The care plan was evaluated at 24 hours. All of the goals were met at this time.
The newborn was weaned to room air after 8 hours. This is based on CBG and CXR within established norms, clear breath sounds, centrally pink, Sa)2 of 99-100% per pulse oximeter while on room air, absence of tachypnea, grunting, flaring, retracting, or acrocyanosis. The radiant warmer was required for 18 hours and thereafter an incubator with neutral thermal environment based on her age and weight probided a warm, safe environment. An eggcrate mattress and bender bumper pad provided for skin integrity protection and helped her to maintain flexion. Her glucose levels remain at 80-130 mg/dl per chemstrip, without the physical signs of hypoglycemia: jitterness, lethargy, temperature instability, or seizures. PIV continues to be secure and patent, without redness or edema at site. D10W IV fluid continues to be infused per IVAC/Burretol at 6 cc/hr. Pulse oximetery and cardiac/apnea monitoring was continued for next 24 hours. After the oxygen therapy was discontinued, the newborn nippled 20cc Lactofree infant formula (20 cal/oz) with reflux problems. She is voiding and stooling adequately. Mother has come into the nursery to hold and visit with the newborn briefly and the father has made two visits, touching and talking to the baby. Both parents verbalized feeling overwhelmed and fearful of caring for such a small baby.
Self Care Deficits (newborn) were reassessed and the following diagnoses were made for the continued care plan.
1. ALTERATION IN NUTRITION: less than body requirements related to prematurity as evidenced by weak and ineffective suck-swallow response.
2. INEFFECTIVE THERMOREGULATION related to prematurity; as evidenced by lack of subcutaneous fat stores and poor flexion.
Health Deviation Demands:
3. POTENTIAL FOR INJURY: Necrotizing Enterocolitis and Intraventricular Hemorrhage related to increased risk from prematurity and NICU environement.
4. ALTERED GROWTH AND DEVELOPMENT related to hospitalization; as evidenced by isolation of incubator, fragility of low birth weight infant, light and noise in NICU.
Dependent Care Agent Deficits: (parents) were assessed and the following diagnoses were made for the continued care plan.
5. ALTERED PARENTING related to separation of neonate from family; as evidenced by neonate's prolonged hospitalization, maintenance in incubator, and mother's complications and hospitalization.
6. ANXIETY related to lack of knowledge about the newborn's condition and future hospitalization; as evidenced by parent's verbalized feelings of being overwhelmed and unsure of how to interact with newborn in NICU setting.
7. KNOWLEDGE DEFICIT: home care of premature infant related to lack of previous experience or teaching.
Summary of Case Study:
The newborn was gavage/nipple fed with great care for 24 hours until she gradually tolerated 45cc every 3 hours as required for her needed growth and maintenance. The IV fluids then were discontinued and the site heplocked. The gavage feedings continued until she was 8 days old when she nippled all of her required feedings. The cardiac/apnea monitor was continued throughout her stay of 28 days due to the risk of apnea of prematurity and to decrease the risk of injury by aspiration of reflux. Her risk for NEC was assessed frequently by abdominal girth, bowel sounds, guaiac stool, and amount of gastric residual. Ampicillin and Gentamicin therapy for 36 hours was provided IV per heplock which was then discontinued. Serum and urine cultures remained negative. CGB at 10 days of age determined pH 7.37. She never lost more than 1 ounce and maintained within the 50th percentile of growth until she exceeded 5 pounds at discharge.
The family was encouraged to spend as much time as possible with the newborn in the nursery. They were gradually included in her care and teaching was given and reinforced with return demonstration. Bonding and confidence increased, as the parents began to take a larger part in their daughter's care. Visual, auditory and physical stimulation was provided by staff who modeled this to the parents. Discharge teaching included infant CPR and continued care requirements, with follow-up by home health nurses to identify needs of parents and newborn once in their own environment.
Kelly, L. (1992). The Nursing Experience: Trends,Challenges and Transitions
(2nd ed.). New York: McGraw-Hill.
Polit, D.F. & Hungler, B.P. (1993). Essentials of Nursing Research: Methods, Appraisal,
and Utilization, (3rd ed.). Philadelphia: J.B. Lippincott.
Speer, K.M. (1990). Pediatric Care Plans. Springhouse Pennsylvania: Springhouse
Tolentino, M.B. (1990). The use of Orem self care model in the neonatal intensive-care
unit. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 19(6), 496-500.
Copyright, ©1997 Debra Kay Neiman,
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