Respiratory distress Care Plan

Question 1

Goals of care

Answer 1

Continue IV therapy and antibiotics
Maintain family centred care
Reduce S+S of respiratory distress
Maintain O2 sats within 90-95%
Decrese respiratory rate and WOB
Maintain BGL >2.6
Maintain a neutral thermal environment
Implement developmental care practices

Question 2

Actual and potential problems

Answer 2

Actual problem:
Respiratory Distress

Potential problems:
- hypoxia
- pulmonary hypertension
- feeding difficulties - NBM
- tachycardia
- hypercapnia and acidosis
- hypoglycaemia
- cold stress
- sepsis
- long term developmental delays

Question 3

Interventions and rationale

Answer 3

Nurse supervised in a prone position
- allows for maximum air intake with the least amount of effort
- Removes pressure from the diaphragm onto the lungs

IV antibiotics
- prophylactic measure to ensure that if respiratory distress is due to an infection, this does not evolve into sepsis

Insert IV cannula and commence glucose 10% 60ml/kg/day and then TPN
- Infants must remain nil by mouth to reduce pressure from the stomach onto the diaphragm
- Ensures adequate nutritional intake to support growth and development alongside recovery from respiratory distress
- prevents hypoglycaemia which can worsen respiratory distress

Clustering cares
- clustering cares protects sleep which optimises recovery

Nurse in a preheated incubator
- preheated ensures there is no heat loss via conduction or radiation initially
- allows neutral thermal environment to be maintained to prevent cold stress which can worsen respiratory distress

Apply cardiorespiratory monitoring and an oxygen probe on the R) hand for pre ductal sats
- allows for constant monitoring of cardiorespiratory function and early identification of deterioration

Question 4

Evaluation

Answer 4

Assess wet and dirty nappies, BGL and temperatures
assess need for respiratory support eg. CPAP
assess for changes in vital signs
Assess for signs infant is ready to stop CPAP eg. pushing off mask