What is the Independent, Dependent, and Collaborative (if possible)…
What is the Independent, Dependent, and Collaborative (if possible) Intervention with the rationale of this given Case Scenario?
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(Assessment, Diagnosis, Planning, and Evaluation are already indicated)
A 30-year-old woman, G2P1L1, delivered a 1.5 kg male via vaginal delivery because of preterm labor at 33 weeks’ gestation. The mother and her spouse expressed confusion and fear about what is happening to their baby. The infant’s apgar scores are 7 and 8 at 1 and 5 minutes, respectively. The infant is cyanotic and requires CPAP immediately after delivery. He has subcostal retractions, grunting, and nasal flaring. Auscultation reveals decreased air entry in the lung fields throughout. Temperature is 98.2°F (36.8°C), pulse is 175 beats per minute, respiratory rate is 70 breaths per minute and SpO2 is 70%. He requires an Fio2 of 0.4. His chest radiograph shows diffuse, bilateral, ground-glass lungs with air bronchograms.
Objective:
- Temp: 36.8 C
PR: 175 bpm
RR: 70 breaths per minute
SpO2: 70%
Weight: 1.5 kg
- Infant is cyanotic and required CPAP after delivery
- Apgar Score: 7 and 8 at 1 and 5 minutes
- Decreased air entry in lung fields
- Subcostal retractions, grunting and nasal flaring
Diagnosis:
Impaired spontaneous ventilation related to abnormal ABGs
Planning
Short Term
After _ hours of nursing intervention, the infant will:
- Will maintain spontaneous gas exchange resulting in normal oxygen saturation, and normal ABGs.
- Will have a respiratory rate of 40-60 bpm.
Evaluation
After _ hours of nursing intervention, the desired goals were met as evidenced by:
- Maintained spontaneous gas exchange resulting in normal oxygen saturation and normal ABGs.
- Respiratory rate maintained at 40-60 bpm.
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