Academic Care Plan
Running head: ACADEMIC CARE PLAN
Academic Care Plan for a NICU Patient
Terri DelCarlo, RN, BSN, FACCE, and Jeanette Koshar, RN, NP, PhD
Juliana Leyda
11/28/2008
Sonoma State University
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Patient Problems
This neonatal intensive care unit [NICU] patient had numerous problems, many of which
I did not address in my care. His history includes early fetal exposure to some alcohol, and
sustained fetal exposure to cigarette smoking, prescription opiates [Ultram and Norco], and
Carbetrol, a pregnancy category “D” anticonvulsant medication with known teratogenic effects.
His mother was unaware of her pregnancy thinking that she was menopausal, and when she
realized her pregnancy she refused to stop using these substances as advised by her doctors.
There were other instances of non-compliance with her prenatal care as well. She developed
pregnancy induced hypertension that was not responsive to medications, and a decision for
cesarean section was made at just under thirty-four weeks. The infant’s Apgar scores were eight
and eight, and he was well formed with the exception of a hypospadias and symptoms of an
inguinal hernia, and or hydroceles, which seemed to clear up. The infant is presently in an
isolette in the NICU, and exhibits several signs of withdrawal, including: a high pitched cry,
hyperreflexivity, short naps, mild tremors, slight fever. Withdrawal symptoms at a score of 13+
require a call to the doctor [MD] and possible intervention. This infant’s score went from three to
ten in the past day.
The family and infant problems are numerous. He is premature and withdrawing from
tobacco and opiates, both of which put him at risk for physical complications. I was concerned
about how his mother would care for his fragile health given the choices she made with her
prenatal care. The following nursing diagnoses describe some of this patient’s physical and
social problems:

Delayed growth and development related to premature birth and weight loss of ninepoint-seven percent since birth.
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
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Disorganized infant behavior related to drug withdrawal as evidenced by: tachypnea,
mottling, ineffective sleep, hyperphagia, tremor, hyperreflexivity, high pitched cry.

Sleep pattern disturbance related to opiate withdrawal as evidenced by: infant wakes
crying within one to two hours after feeding.

Risk for sudden infant death syndrome related to prematurity, tobacco exposure, and
opiate withdrawal.

Risk for injury related to seizures secondary to opiate withdrawal.

Risk for injury related to hemolytic disease in the setting of prematurity as evidenced by:
jaundice developing on face.

Risk for ineffective sexual pattern related to dysmorphism as evidenced by: hypospadias,
hernia(s), hydroceles.

Interrupted family processes related to hospitalized infant as evidenced by: parents and
infant are not with each other the majority of the time as they would be without infant’s
illness.

Mom: decisional conflict related to her need to medicate her chronic pain and seizure
disorder, versus the risk of injuring fetus with those medications, as evidenced by mom’s
continued use of these medications against medical counsel.

Interrupted breast-feeding related to maternal cesarean section, subsequent discharge
from hospital, and infant’s continued hospitalization as evidenced by: mom is not at
hospital to breast feed because she is recovering at home, and is not producing adequate
milk supply yet.

Ineffective management of therapeutic regimen by mother related to poor compliance
with medical instruction as evidenced by: no-showing to prenatal care appointments,
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leaving hospital against medical advice, and not completing ordered prenatal screening
tests.

Risk for disturbed maternal/paternal self concept related to infant illness resulting from
maternal health choices.

Impaired parenting and non-compliance related to maternal use of tobacco and
prescription drugs as evidenced by: refusal to stop taking opiate and teratogenic
medications upon realizing pregnancy, against medical advice and despite knowledge of
risks to infant.

Knowledge deficit related to care of an ill infant as evidenced by: this is the parents’ third
child, but first ill infant.
(Ackley & Ladwig, 2004; Carpenito, 2002.)
Nursing Theory
To me, infants are fairly simple in their needs, and in the setting of the NICU it is
easy to think that infants are eating-breathing-eliminating-sleeping machines, because little
play or social stimulation is involved in their nursing care. In addition to being born
premature, this infant is withdrawing from tobacco and prescription opiates that his mother
used during her pregnancy. Faye Glenn Abdellah (1960) states that care should be patient
centered and focused on not just the physical needs of the patient, but also their sociological
and emotional needs. In caring for this infant, I had my attention and problem-solving skills
focused on his physical, emotional, and social needs. For my care, I considered the infant’s
physical needs in the setting of his prematurity, weight loss, and withdrawal. This infant also
had emotional needs: because he was withdrawing his brain interpreted an otherwise
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comfortable situation as uncomfortable and he awoke crying frequently. I prioritized comfort
because if Abdellah is correct, his emotional and physical comfort will positively or
negatively affect his physical health. I also considered his social needs: his mother knew she
was pregnant but did not stop using several substances that were damaging to her infant that
her doctors told her to abstain from. I felt that an assessment and education of the family
were in order because her health management during pregnancy did not bode well for an ill
infant with unique needs.
Referrals
I had concern for this infant’s parents’ emotional needs, and their knowledge of their
son’s health needs. I would refer these parents to the Memorial Hospital’s “Doctor Talk,” a twohour open forum provided for the public to ask questions of physicians (information can be
found at: https://stjoseph.healthvision.com/classesevents/childbirth.htm). I would also refer them
to a support group for parents of NICU infants, many online and local offline groups can be
found at this website: www.preemieparenting.com/supportgroups.htm.
To support mom with continuing breast feeding despite her infant’s hospitalization, I
would refer her to the hospital’s lactation consultant. This expert would be able to provide
specialized advice, and assess and coach the mom-newborn dyad at the NICU. I would also give
her information for La Leche League, and hospital educational materials to help her with breast
feeding—she may not know the special benefits of breast milk to her child, and may need
support and encouragement.
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Nursing Diagnosis: Impaired comfort related to central nervous system irritability secondary to
tobacco and opiate withdrawal as evidenced by: tachypnea, ineffective sleep, hyperphagia,
tremor, hyperreflexivity, and high pitched cry.
Assessment:
Expected
Interventions: Rationale:
Evaluation:
(the client has)
Outcome
(the RN
(the client
does…)
will…)
Tachypnea
1: Sleep up A: Decreases
A: Light and noise are stimuli 1: Partially
(respiratory rate
to two hours noise in
that might trigger
met: infant
sometimes
after
NICU,
hyperactivity and irritability.
awoke one
greater than
feedings by opens/closes
Clustering care allows longer hour after
sixty/min).
end of shift. isolette doors
sleep periods and decreases
feeding.
quietly, dims
noise and irritability
Ineffective
lights
(Hockenberry & Wilson,
Sleep: infant
2:
Display
overhead,
2008, p 407).
2: Met:
sleeps only about
no signs of
covers isolette
infant
one half or one
abstinence
with
a
blanket,
showed no
hour after
within one
clusters care.
signs of
feeding, three
week
[he
abstinence
hours would be
will have
B: Swaddles
B: Some infants are
seven days
normal.
normal
the infant with comforted by the warmth and later.
Hyperphagia:
reflexivity,
arms flexed,
containment of swaddling.
this infant
tone,
‘nests’ him in Flexed arms allow infant to
suckles readily
respiratory
isolette with
suck fingers, which helps
and eats quickly. rate, cry,
rolled
them to self soothe
and
no
blankets.
(Hockenberry & Wilson,
Tremor: infant
tremor.]
2008, p 407).
twitches when
undisturbed-3: Prevents
C: Responds
C: Crying signals a need,
3: Met:
when disturbed,
seizure in
quickly to
infants cry for shorter periods Infant
twitching
infant.
crying.
if comforted at outset of
suffered no
intensifies to
crying (Hockenberry &
seizures.
outright tremors.
Wilson, 2008 p 521).
Increased tone.
Hyperreflexivity:
hyper Moro
reflex.
High pitched,
shrill cry.
D: Maintains
comfortable
temperature by
swaddling and
adjusting
isolette
thermostat,
monitors
axillary
temperature.
D: Infants, especially preterm
infants cannot regulate their
own temperature adequately.
Infant will be most
comfortable if we keep his
temperature within normal
limits (thirty six point five to
thirty seven point two degrees
Celsius) (Hockenberry &
Wilson, 2008, p 350).
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E: Feeds infant
per MD
orders. Feeds
infant in arms,
burping
frequently.
Keeps infant’s
diaper dry.
E: Withdrawing infants are
prone to projectile vomiting.
Infant will use food and close
contact for comfort
(Hockenberry & Wilson,
2008, p 407), and needs to be
burped to maximize comfort
and minimize regurgitation,
as his cardiac sphincter is
immature and he eats quickly
(Lowdermilk & Perry, 2007,
p 642).
F: Monitors
infant’s
withdrawal
symptoms and
notifies MD
per protocol.
F: Infants are at risk for
seizures when they are
withdrawing. If their
abstinence score increases to
a certain point, MD may
prescribe medications (like
diluted tincture of opium) to
decrease symptoms and risk
of seizure (ATI MaternalNewborn Module, p 443).
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Nursing Diagnosis: Delayed growth and development related to premature birth and interruption
of total parenteral nutrition feedings as evidenced by birth at thirty-four weeks gestation, birth
weight of nineteen hundred five grams, and weight loss of nine-point-seven percent since birth.
Assessment:
Expected
Interventions: Rationale:
Evaluation:
(the client has)
Outcome
(the RN
(the client
does…)
will…)
Birth weight of
1: Tolerate
A: Assess
A: Preterm infants can be
1: Met:
nineteen hundred oral
infant’s
fatigued by oral feeding, or
infant
five grams [g].
feedings
strength and
may not have a coordinated
tolerated his
within one
endurance for suck-swallow reflex
first day of
day.
oral feedings.
(Lowdermilk & Perry, 2007,
oral
Current weight
p 1064).
feedings
of seventeen
without
hundred nineteen
B: Feed small B: Small amounts are less
difficulty.
g.
amounts per
tiring to ingest and less likely
2: Will not
MD order,
to cause discomfort,
2: Met:
vomit
increase
distension, and vomiting
patient did
Weight loss of
during or
feedings
(Lowdermilk & Perry, 2007,
not vomit
one hundred
after
slowly to
p 1064), slow increase of
during or
eighty five g or
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nine-point-seven
percent. Weight
loss of fifteen
percent in the
first week is
expected in
preterm infants:
they are
predisposed to
weight loss
because of their
greater fluid
volume, low
reserves, and
their immature
gastrointestinal
tracts
inadequately
absorb nutrients
(Lowdermilk &
Perry, 2007, p
1063).
Gestational age
of thirty four
weeks by exam.
Interruption of
total parenteral
nutrition [TPN]
feedings because
of repeatedly
infiltrated and
clotted
intravenous
access sites [IV],
followed by ten
unsuccessful IV
attempts.
Feedings were
advanced early
and oral feeding
is being
attempted, with
gavage feeding
feedings.
3: Gain
back birth
weight
within one
week.
4: Receive
breast milk
from his
mother.
thirty five
milliliters
[mL] every
three hours.
C: Burp infant
frequently
during
feedings.
D: Comfort
infant and
allow him to
suck on
fingers or
pacifier.
E: Encourage
mother to
pump milk
although her
infant is in
NICU and she
is recovering
from surgery
at home,
educate her on
the best
pumping
methods to
support milk
supply,
attempt breast
feedings easier to tolerate and
less likely to cause
overfeeding (p 1072).
8
after
feedings.
3: Met:
Infant
C: Withdrawing infants either weighed
feed weakly, or suckle fiercly, eighteen
eat quickly, and then
hundred
projectile vomit.
forty-three
(Hockenberry & Wilson,
g within one
2008, p 407) This infant eats
week.
rapidly and needs frequent
(ninetyburping to both slow his
seven
eating and minimize
percent of
regurgitation as his cardiac
birth
sphincter is immature
weight—
(Lowdermilk & Perry, 2007,
close
p 642). Vomiting means he
enough for
will absorb less food and gain me!).
less weight.
4: Partially
D: Nonnutritive sucking
met: mom
offers infant comfort,
was
increases oxygenation, and is pumping at
connected to positive weight
home, but
gain and later attachment to
only able to
the nipple during breast
provide five
feeding (Lowdermilk &
to fifteen
Perry, 2007, p 1067).
mL of
breast milk
E: Mother’s milk is the best
at her visits,
food for this infant. Mom is at and formula
risk to have diminished milk
was added
supply because of cesareanto it.
section and interrupted breast
feeding, and will need
encouragement and support to
maintain her supply without
her infant’s presence at the
breast. The pair’s chances of
breast feeding long-term are
increased if they initiate
latching on and breast feeding
early (Lowdermilk & Perry,
2007, 1064).
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as a back up
plan.
9
feeding in
NICU.
Nursing Diagnosis: Interrupted breast-feeding related to cesarean section, separation of mombaby dyad because of mom’s early discharge from hospital and subsequent recovery at home,
and infant’s continued hospitalization as evidenced by: mother not yet visiting the hospital to
breast feed, mom is not producing an adequate milk supply yet, infant has never been at the
breast.
Assessment:
Expected
Interventions: Rationale:
Evaluation:
(the client has)
Outcome
(the RN
(the client
does…)
will…)
No mother at
1: Mom will A: Assess
A: Assessing interest is a
1: Unmet:
bedside because
produce
mom’s interest place to start education and to one week
she is home
adequate
in breast
gauge her willingness to
later mom
recovering from
supply of
feeding, and
comply with pumping
had stopped
a cesarean
breast milk
how she is
instruction. Mom’s pump and pumping
section.
within one
pumping
pumping schedule may be
milk,
week.
currently:
how
adequate,
or
there
may
be
because she
Infant has not yet
often,
how
ways
to
improve
milk
supply
was not
been at the breast
long, what
that she doesn’t know about
really
to suckle yet.
kind of pump
(Lowdermilk & Perry, 2007,
committed
Mom is pumping
she uses.
p 725).
to breast
breast milk at
feeding.
home.
B: Encourage B: Bilateral pumping, eight to
2: Mom will pumping
ten times daily for ten to
2: Partially
Mom is
bilaterally
fifteen minutes supports
met: mom
producing five to continue
pumping
with a hospital better milk let-down. Hospital and dad did
fifteen mL of
breast milk
grade pump,
grade pumps are the most like deliver
breast milk per
at home and eight to ten
infant feeding and support
small
day-- this is her
it
will
be
times
daily
for
milk
supply—they
are
best
amounts of
third day
delivered to ten to fifteen
for moms separated from their breast milk
postpartum.
the hospital. minutes
infants. Increased fluid intake to the NICU
Father is
(Lowdermilk
and good diet supports
until mom
bringing pumped
& Perry, 2007, healthy milk supply
stopped
breast milk to
p 725), and
(Lowdermilk & Perry, 2007,
pumping.
hospital when
increasing her p 726-9).
visiting his son.
3: Mom and fluid intake
3: Unmet:
baby will
and
latch on was
successfully maintaining a
not
breast feed
nutritious diet.
attempted
during their
and breast
NICU stay
C: Assess milk C: Starting breast feeding
feeding
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and
continue
breast
feeding for
the baby’s
first six
months.
supply and any
difficulties,
refer to a
lactation
consultant if
needed.
without the baby is difficult,
mom may need extra help and
specialized support in breast
feeding (Lowdermilk &
Perry, 2007, p 735).
D: Praise mom
for pumping,
and mom and
dad for getting
pumped milk
to the hospital,
remind them
of the benefits
to their son’s
health,
especially
given his
prematurity.
D: Until her milk supply
increases, it might seem
unimportant to the parents to
trouble themselves with
ferrying milk to the hospital.
Emotional support and
positive reinforcement will
encourage them to continue
bringing any amount of breast
milk to the NICU. Breast milk
is the best food for preterm
infants because it reduces risk
of necrotizing enterocolitis,
improves neurocognitive
outcomes and physiologic
stability (Lowdermilk &
Perry, 2007, p 725).
E: Support
mom in
attempting
breast feeding
in the NICU as
soon as she
feels ready:
perhaps at the
same time a
lactation
consultant can
assist.
E: Many preterm infants are
capable of breast feeding.
This infant suckles vigorously
and could be an excellent
breast feeder, especially if
breast feeding is initiated
soon, before nipple confusion
sets in. A lactation consultant
might offer extra help to the
pair. (Lowdermilk & Perry,
2007, p 724). There is no
need to delay this infant’s
breast feeding, as he is fairly
stable: “The current practice
of delaying breast feeding
until the [preterm] baby is
able to bottle-feed is not
evidence based” (Callen &
Pinelli, as cited in
Lowdermilk & Perry, 2007, p
1064).
stopped
within the
week.
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F: If mom is
unable to
breast feed,
advocate for a
prescription
for donation
from the milk
bank.
F: Breast milk is still the best
food for this infant, and if
mom cannot provide it,
banked milk is available by
prescription for NICU
patients. (Lowdermilk and
Perry, p 729).
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References
Abdellah, F. G., Beland, I. I., Martin, A., & Matheney, R. V. (1960). Patient-centered
approaches in nursing. New York: Macmillan.
Ackley, B., & Ladwig, G. (2004). Nursing diagnosis handbook: A guide to planning care (6th
ed.). St. Louis: Mosby.
Callen, J., & Pinelli, J. (2005). A review of the literature examining the benefits and challenges,
incidence and duration, and barriers to breast feeding in preterm infants. Advances in
Neonatal Care, 5(2), 72-88.
Carpenito, L. (2002). Nursing diagnosis: Application to clinical practice. Philadelphia, PA:
Lippincott.
Hockenberry, M., & Wilson, D. (2008). Wong’s nursing care of infants and children (8th ed.). St.
Louis, MO: Mosby.
Lowdermilk, D., & Perry, S. (2007). Maternity & women’s health care (9th ed.). St. Louis, MO:
Mosby.
Wiismann, J., Stomoly, J., Lawler, K. M., Stacy, B. L., & Easterby, L. (2007). Registered nurse
maternal newborn nursing review module (Edition 7.1). Stilwell, KS: Assessment
Technologies Institute, LLC.