- Give isolation / monitor visitors as indicated.
- Wash hands before and after doing the activity even when wearing gloves.
- Limit the use of tools / invasive procedures if possible.
- Use sterile technique.
- Monitor the temperature / temperature increase on a regular basis
- Observe the chills.
- Monitor the client's vital signs.
- Collaboration with the medical team in the administration of antibiotics.
2. Hyperthermia / hypothermia related to an increase in metabolic rate, vasoconstriction / vasodilation of blood vessels.
- Monitor the client's temperature (degrees and patterns) note chills / diaphoresis.
- Monitor the ambient temperature / ambient temperature setting.
- Isolation child / baby in an incubator.
- Give compress (cold, warm) if there is an increase / decrease in temperature.
- Note the increase / decrease in the baby's body temperature.
- Collaboration with the medical team in laboratory tests (increased leukocytes).
3. Ineffective tissue perfusion related to decreased oxygen supply / irregular breathing.
Review of the pattern of growth or decline in the number of prenatal and amniotic fluid as detected by ultrasonography.
- Note the type of birth and incidence of intra-partum hypoxia signaling.
- Note the time and Apgar scores, respiratory pattern observation.
- Assess respiratory rate, depth, effort, observation and report signs and symptoms of respiratory distress, distinguish from symptoms associated with polycythemia.
- Auscultation of breath sounds on a regular basis.
- Nasopharyngeal suction hose as needed, after the first oxygen supplementation.
- Auscultation apical pulse, note the presence of cyanosis.
- Latrogenik prevent complications related to cold distress, metabolic imbalances and insufficient calories.
- Monitor the pulse oximeter readings.
- Monitor laboratory tests as indicated, serum pH, blood gas analysis, and HT.
- Give a warm and humid oxygen, provide assistance vertilasi as indicated.
- Perform suction.
- Avoid execution of suction that is too often.
- Observation and review of infant response to oxygen therapy.
4. Risk for fluid volume deficit related to diarrhea, vomiting and fluid shifts from the interstitial to the vascular.
- Monitor intake and output.
- Measure body weight every day.
- Monitor blood electrolyte levels, blood urea nitrogen, urine and serum osmolality, creatinine, hematocrit and hemoglobin.
- Assess body temperature, moisture in the oral cavity, the volume and concentration of urine.
- Give: liquid forms an interesting, unusual containers (colored cups, straws) and a game or activity (send the child to drink when the time came for the child).
5. Imbalanced Nutrition: less than body requirements related to nausea, vomiting and increased metabolism.
Assess the weight in relation to gestational age and size. Documented on a growth chart. Measure body weight every day.
- Keep termonetral environment, including the use of incubators as indicated. Monitor the temperature of the heater baby and the environment with frequently.
- Do it early and often feeding and proceed according to tolerance.
- Assess tolerance to food. Note the stool color, consistency and frequency, a decrease in substance, abdominal circumference, vomiting and gastric residue.
- Monitor input and output. Calculate caloric and electrolyte intake every day.
- Assess the level of dehydration, note the fontanelle, skin turgor, urine specific gravity, the condition of the mucous membrane and weight fluctuations.
- Monitor Dextrosix levels immediately after birth and regularly until serum glucose stabilized.
- Review the signs of hypoglycemia.
- Monitor laboratory tests as indicated
- Give electrolyte supplements as indicated.
- Create an intravascular access as indicated.
- Give parenteral nutrition.
- Discuss long-term complications of malnutrition in infants SGA and LGA infants obesity, discuss the importance of brain growth protein subs (Doenges, 2000).
