Nursing Diagnosis : Ineffective Breathing Pattern
According Proverawati (2010), Clinical / LBW Infants characteristics:
- Weight less than 2500 grams.
- Length of less than 45 cm.
- Chest circumference less than 30 cm.
- Head circumference less than 33 cm.
- Thin subcutaneous fat tissue or less.
- Gestational age less than 37 weeks.
- Larger heads.
- Transparent thin skin, lanugo hair a lot, less fat.
- Cartilage earlobe, rudimentary growth.
- Weak hypotonic muscle is a muscle that is no active movement of the arms and elbows.
- Irregular breathing can occur apnea.
- Extremities: abduction of the thigh, the knee / leg flexion-straight, heel shiny, smooth soles.
- Head is not able to erect, yet nerve function or ineffective and weak tears.
- Breathing 40-50 times / min and pulse 100-140 beats / min.
Nursing Diagnosis for Low Birth Weight : Ineffective breathing pattern related to the immaturity of the respiratory center, the limitations of muscle growth or decline in muscle weakness and metabolic imbalance.
Goal: Patterns breath back effectively.
Expected outcomes:
Neonates will maintain periodic breathing patterns.
Pink mucous membranes.
Nursing Interventions :
Independent:
Assess the frequency and pattern of breathing, note the presence of apnea and cardiac frequency changes.
Suction the airway as needed.
Place the baby in the abdomen or supine position with a rolled diaper under the shoulder to produce hyperextension.
Review the history of the mother to drugs that would aggravate respiratory depression in infants.
Collaboration:
Monitor laboratory tests as indicated.
Give oxygen as indicated.
Give medications as indicated.
Rationale :
Help in distinguishing normal breathing rotation period of true apnea attacks, especially common in the 30th week of gestation.
Eliminate mucus that clogs the airways.
This position facilitates breathing and decrease episodes of apnea, especially if found any hypoxia, metabolic acidosis or hypercapnia.
Magnesium sulfate and narcotics suppress the respiratory center and CNS activity.
Hypoxia, metabolic acidosis, hypercapnia, hypoglycemia, hypocalcemia and sepsis aggravate apnea attacks.
Improvement of oxygen and carbon dioxide levels can improve respiratory function.