What is the Nursing Intervention (Independent, Dependent, and…
Question What is the Nursing Intervention (Independent, Dependent, and… What is the Nursing Intervention (Independent, Dependent, and Collaborative) with Rationale of this Case Scenario? A 30-year-old woman, G2T1P1A0L1, 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 newborn’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. ASSESSMENT: Objective: TR:98°F (36.8°C)PR: 175 bpmRR: 70 breaths per minuteSpO2: 70%Weight: 1.5 kgApgar scores are 7 and 8 at 1 and 5 minutesCyanoticSubcostalRetractionsGruntingNasal FlaringDIAGNOSIS: Ineffective breathing pattern related to abnormal breath sounds PLANNING: Short TermAfter 4 hours of nursing intervention, the newborn will:Have a normal, effective respiratory pattern as evidence of absence of grunting sounds and flared nostrils.EVALUATION: After 4 hours of nursing intervention, the desired goals were met as evidenced by:Establish a normal, effective respiratory pattern as evidence of absence of grunting sounds and flared nostrils. Health Science Science Nursing Share QuestionEmailCopy link Comments (0)
