Premature infants, born before 37 weeks of gestation, face unique challenges in adapting to extrauterine life. Their bodies are not fully developed, making them vulnerable to various health complications. This article will focus on key nursing diagnoses relevant to premature infants, providing a comprehensive guide for nurses to develop effective care plans and improve outcomes for these delicate newborns. Understanding the specific needs of preterm infants is crucial for healthcare professionals to provide optimal care and support during their critical early days and weeks.
Common Nursing Diagnoses for Premature Infants
Nurses play a vital role in the care of premature infants, from initial assessment in the Neonatal Intensive Care Unit (NICU) to educating parents for discharge. Identifying appropriate nursing diagnoses is the first step in creating individualized care plans. These diagnoses address the increased risks and vulnerabilities associated with prematurity, such as respiratory distress, thermoregulation difficulties, feeding challenges, and susceptibility to infection. Utilizing nursing care plans ensures a systematic approach to assessment, intervention, and evaluation of care for premature infants, promoting the best possible start in life.
Imbalanced Nutrition: Less Than Body Requirements in Premature Infants
Premature infants are at high risk for imbalanced nutrition due to their immature digestive systems, poor sucking and swallowing reflexes, and increased metabolic needs. Conditions associated with prematurity often exacerbate these challenges, requiring vigilant nutritional support.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related to:
- Prematurity and gestational age immaturity
- Poorly developed suck and swallow reflexes
- Increased caloric needs due to rapid growth and development
- Necrotizing enterocolitis (NEC) risk
- Respiratory distress and increased energy expenditure
- Parenteral or enteral feeding challenges
- Underlying congenital anomalies
As evidenced by:
- Weight below the 10th percentile for gestational age
- Poor weight gain or weight loss
- Lethargy and decreased muscle tone
- Poor feeding tolerance, vomiting, or abdominal distention
- Delayed gastric emptying
- Electrolyte imbalances
- Hypoglycemia
Expected outcomes:
- Premature infant will demonstrate consistent weight gain appropriate for gestational age and clinical condition.
- Premature infant will tolerate feedings (enteral or parenteral) without signs of distress.
- Premature infant will maintain stable blood glucose and electrolyte levels.
- Premature infant will exhibit age-appropriate activity and muscle tone.
Assessment:
1. Evaluate gestational age and birth weight. Gestational age is a primary determinant of prematurity and associated risks. Lower gestational ages correlate with more significant immaturity and nutritional challenges.
2. Assess feeding abilities and reflexes. Observe the infant’s suck, swallow, and gag reflexes. Premature infants often have weak or uncoordinated reflexes impacting oral feeding success.
3. Monitor intake and output closely. Accurate measurement of intake (oral, gavage, parenteral) and output (urine, stool, emesis, drainage) is essential for assessing fluid balance and nutritional status.
4. Assess for signs of feeding intolerance. Monitor for vomiting, abdominal distention, increased residuals, changes in stool pattern, and signs of discomfort during or after feedings. These can indicate necrotizing enterocolitis or other feeding problems.
5. Regularly monitor weight, length, and head circumference. Growth parameters are critical indicators of nutritional adequacy in premature infants. Plot growth on appropriate preterm growth charts.
6. Monitor blood glucose and electrolytes. Premature infants are prone to hypoglycemia and electrolyte imbalances, which can be exacerbated by inadequate nutrition.
Interventions:
1. Implement appropriate feeding methods. Determine the most appropriate feeding method based on gestational age, clinical stability, and feeding abilities. This may include parenteral nutrition (TPN), enteral nutrition via nasogastric (NG) or orogastric (OG) tube, or oral feeding.
2. Provide parenteral nutrition as indicated. TPN provides essential nutrients intravenously when enteral feeding is not feasible or sufficient, especially in extremely premature infants.
3. Initiate enteral feedings cautiously and advance gradually. Start with minimal enteral nutrition (MEN) or trophic feeds and gradually increase volume and concentration as tolerated. Monitor closely for signs of intolerance.
4. Consider breast milk or donor human milk. Breast milk is the optimal nutrition for premature infants, providing immunological benefits and easily digestible nutrients. If mother’s milk is unavailable, donor human milk is the next best option.
5. Supplement breast milk or formula as needed. Premature infants often require supplementation with human milk fortifier or preterm formula to meet their increased nutritional demands.
6. Position infant appropriately for feedings. Positioning the infant upright or side-lying during feedings can improve feeding tolerance and reduce the risk of aspiration.
7. Provide non-nutritive sucking during gavage feedings. Non-nutritive sucking (pacifier) during gavage feedings can promote digestion, improve feeding tolerance, and provide comfort.
8. Collaborate with a registered dietitian. A dietitian specializing in neonatal nutrition can provide expert guidance on nutritional assessment, planning, and monitoring.
Risk for Ineffective Thermoregulation in Premature Infants
Premature infants are highly susceptible to hypothermia due to several factors related to their immature physiology. Their large surface area to body weight ratio, thin skin, lack of subcutaneous fat, and limited ability to generate heat put them at significant risk.
Nursing Diagnosis: Risk for Ineffective Thermoregulation
Related to:
- Prematurity and decreased subcutaneous fat
- Large surface area in proportion to body mass
- Thin epidermis and reduced insulation
- Limited brown fat stores
- Immature thermoregulatory center
- Inability to shiver effectively
- Cold environment of the NICU
- Radiant heat loss from incubators
- Evaporative heat loss after bathing
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Premature infant will maintain body temperature within the normal range (36.5°C to 37.5°C or 97.7°F to 99.5°F).
- Premature infant will exhibit stable vital signs within normal limits.
- Premature infant will demonstrate appropriate activity levels and muscle tone.
- Parents/caregivers will demonstrate understanding of thermoregulation and hypothermia prevention in premature infants.
Assessment:
1. Continuously monitor body temperature. Use appropriate temperature monitoring methods such as skin probes or axillary thermometers. Rectal temperatures are generally avoided due to the risk of perforation.
2. Assess environmental temperature and humidity. Maintain the NICU environment within recommended temperature and humidity ranges for premature infants.
3. Observe for signs of cold stress. Monitor for signs of hypothermia such as decreased activity, lethargy, poor feeding, bradycardia, hypoglycemia, and respiratory distress.
4. Assess skin color and perfusion. Note any pallor, mottling, or cyanosis, which can indicate poor thermoregulation and peripheral vasoconstriction.
5. Evaluate incubator settings and radiant warmer usage. Ensure incubator temperature and humidity are appropriately set and radiant warmers are used judiciously to prevent overheating or excessive heat loss.
Interventions:
1. Maintain a neutral thermal environment. Utilize incubators, radiant warmers, and warmed humidified air to minimize heat loss and maintain a stable body temperature.
2. Use skin-to-skin contact (kangaroo care). Kangaroo care is highly effective in maintaining infant temperature, promoting bonding, and improving physiological stability.
3. Apply warmed and humidified oxygen. If oxygen therapy is required, ensure it is warmed and humidified to prevent heat and moisture loss through the respiratory tract.
4. Minimize exposure during procedures. Cluster care activities to minimize handling and exposure to cold environments. Use pre-warmed blankets and surfaces during procedures.
5. Keep infant dry and well-swaddled when out of the incubator. Dry the infant thoroughly after bathing and swaddle snugly in warmed blankets to reduce evaporative and convective heat loss.
6. Utilize heat shields or double-walled incubators. These measures can reduce radiant heat loss from the incubator and maintain a more stable thermal environment.
7. Educate parents on thermoregulation and prevention of hypothermia. Teach parents about the risks of hypothermia, proper clothing, and environmental control for when the infant is discharged home.
Risk for Impaired Gas Exchange in Premature Infants
Respiratory distress syndrome (RDS) is a common and serious complication of prematurity caused by surfactant deficiency and structural immaturity of the lungs. Premature infants are also at risk for apnea of prematurity, bronchopulmonary dysplasia (BPD), and other respiratory problems leading to impaired gas exchange.
Nursing Diagnosis: Risk for Impaired Gas Exchange
Related to:
- Prematurity and surfactant deficiency
- Immature lung development
- Apnea of prematurity
- Respiratory Distress Syndrome (RDS)
- Bronchopulmonary Dysplasia (BPD)
- Meconium aspiration syndrome
- Pneumonia or sepsis
- Patent Ductus Arteriosus (PDA)
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention and early detection.
Expected outcomes:
- Premature infant will maintain oxygen saturation within the prescribed range.
- Premature infant will exhibit a respiratory rate and pattern appropriate for gestational age and clinical condition.
- Premature infant will have clear breath sounds on auscultation.
- Premature infant will maintain arterial blood gases (ABGs) within normal limits for age.
- Premature infant will be free from signs of respiratory distress (nasal flaring, retractions, grunting, cyanosis).
Assessment:
1. Continuously monitor respiratory rate, pattern, and effort. Assess for tachypnea, bradypnea, apnea, irregular breathing, nasal flaring, retractions, and grunting.
2. Monitor oxygen saturation continuously. Use pulse oximetry to continuously monitor oxygen saturation (SpO2) and maintain within the prescribed target range.
3. Auscultate breath sounds regularly. Assess for adventitious breath sounds such as crackles, wheezes, or decreased breath sounds, which may indicate respiratory complications.
4. Monitor arterial blood gases (ABGs). Obtain ABGs as ordered to assess oxygenation, ventilation, and acid-base balance.
5. Assess for signs of cyanosis. Observe for central cyanosis (around the mouth and trunk) and peripheral cyanosis (in extremities), which indicate hypoxemia.
6. Evaluate chest X-rays as ordered. Chest X-rays can help diagnose RDS, pneumonia, and other respiratory conditions.
Interventions:
1. Administer supplemental oxygen as prescribed. Oxygen therapy may be delivered via nasal cannula, CPAP, or mechanical ventilation, depending on the severity of respiratory distress.
2. Provide respiratory support as needed. CPAP (Continuous Positive Airway Pressure) and mechanical ventilation may be required to support oxygenation and ventilation in severe RDS or apnea.
3. Administer surfactant replacement therapy. Surfactant replacement therapy is crucial for infants with RDS to improve lung compliance and gas exchange.
4. Position infant to optimize respiratory function. Place the infant in a prone or side-lying position to improve lung expansion and reduce abdominal pressure on the diaphragm.
5. Suction airway as needed. Suction the airway gently to remove secretions and maintain airway patency. Avoid deep suctioning which can cause trauma and hypoxia.
6. Monitor for complications of respiratory support. Closely monitor for complications of mechanical ventilation such as pneumothorax, infection, and BPD.
7. Provide chest physiotherapy as ordered. Chest physiotherapy may be used to help mobilize secretions and improve airway clearance.
8. Maintain fluid balance carefully. Fluid overload can worsen respiratory distress, while dehydration can lead to thickened secretions. Maintain careful fluid balance.
Risk for Impaired Skin Integrity in Premature Infants
The skin of premature infants is extremely fragile and permeable due to its thin epidermis and underdeveloped stratum corneum. This makes them highly vulnerable to skin breakdown, infection, and transepidermal water loss.
Nursing Diagnosis: Risk for Impaired Skin Integrity
Related to:
- Prematurity and thin, fragile skin
- Increased skin permeability and transepidermal water loss
- Exposure to adhesives and medical devices
- Friction and pressure from positioning
- Moisture from incontinence and diaper rash
- Immature immune system and increased risk of infection
- Nutritional deficiencies
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Premature infant will maintain intact skin integrity without signs of breakdown or infection.
- Premature infant will exhibit appropriate skin turgor and hydration.
- Parents/caregivers will demonstrate proper skin care techniques for premature infants.
Assessment:
1. Perform frequent and thorough skin assessments. Assess skin condition at least every shift, paying particular attention to pressure points, areas under medical devices, and diaper area.
2. Assess gestational age and skin maturity. Extremely premature infants have the most fragile skin and require the most meticulous skin care.
3. Monitor for signs of skin breakdown. Assess for redness, blanching, blisters, erosion, or open areas, especially in areas of pressure or friction.
4. Assess hydration status. Evaluate skin turgor, mucous membranes, and urine output to assess hydration, which affects skin integrity.
5. Review medical device placement and securement. Assess the placement and securement of endotracheal tubes, IV lines, and monitoring electrodes to prevent skin injury.
Interventions:
1. Handle infant gently and minimize friction. Use gentle handling techniques and avoid dragging or pulling the infant across surfaces.
2. Use appropriate skin cleansers and emollients. Use pH-neutral, fragrance-free cleansers and apply emollients to maintain skin hydration and barrier function.
3. Minimize tape and adhesive use. Use hydrocolloid dressings or tape sparingly and consider using stockinette or mesh wraps for securement when possible.
4. Rotate and reposition infant frequently. Reposition the infant every 2-3 hours to relieve pressure and prevent skin breakdown, especially on bony prominences.
5. Use pressure-redistributing surfaces. Utilize gel pads, air mattresses, or specialized infant beds to reduce pressure on vulnerable skin areas.
6. Keep skin clean and dry. Cleanse the diaper area gently with each diaper change and apply a barrier cream if needed. Ensure skin folds are dry.
7. Protect skin from moisture. Use absorbent diapers and change them frequently. Consider air-drying the diaper area to minimize moisture exposure.
8. Educate parents on gentle skin care practices. Teach parents about proper bathing techniques, diaper care, and the importance of avoiding harsh soaps and lotions.
Risk for Infection in Premature Infants
Premature infants have an immature immune system, making them highly vulnerable to infections. They have decreased levels of maternal antibodies, impaired neutrophil function, and thin skin, all contributing to increased susceptibility to both nosocomial and community-acquired infections.
Nursing Diagnosis: Risk for Infection
Related to:
- Prematurity and immature immune system
- Decreased transplacental transfer of maternal antibodies
- Neutropenia and impaired neutrophil function
- Invasive procedures and lines (IVs, catheters)
- Prolonged hospital stay and exposure to nosocomial pathogens
- Skin breakdown and impaired barrier function
- Lack of normal flora colonization
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Premature infant will remain free from signs and symptoms of infection.
- Premature infant will maintain normal vital signs, including temperature, heart rate, and respiratory rate.
- Premature infant will have negative blood cultures and other cultures as indicated.
- Parents/caregivers will demonstrate understanding of infection prevention measures.
Assessment:
1. Monitor vital signs closely. Assess temperature, heart rate, respiratory rate, and blood pressure regularly for any signs of instability or infection.
2. Observe for subtle signs of infection. Premature infants may not exhibit classic signs of infection. Monitor for lethargy, poor feeding, irritability, temperature instability, apnea, and changes in skin color.
3. Assess for risk factors for infection. Identify risk factors such as gestational age, prolonged rupture of membranes, maternal infection, invasive procedures, and prolonged hospitalization.
4. Monitor white blood cell count (WBC) and differential. Changes in WBC count, especially neutropenia or a shift to bands, can indicate infection.
5. Review culture results. Monitor blood cultures, urine cultures, CSF cultures, and tracheal aspirate cultures as indicated to detect and identify infections.
Interventions:
1. Strict adherence to hand hygiene. Perform meticulous hand hygiene before and after every patient contact and procedure. Ensure all healthcare providers and visitors adhere to hand hygiene protocols.
2. Maintain aseptic technique during invasive procedures. Use sterile technique when inserting and managing IV lines, central lines, urinary catheters, and endotracheal tubes.
3. Provide meticulous skin and line care. Perform daily chlorhexidine baths, cleanse insertion sites with chlorhexidine, and change dressings according to hospital policy.
4. Promote breastfeeding. Breast milk provides immunoglobulins and other protective factors that can reduce the risk of infection in premature infants.
5. Limit visitors and screen for illness. Restrict visitors, especially during outbreaks of respiratory infections. Screen visitors for signs of illness and ensure they practice hand hygiene.
6. Administer prophylactic antibiotics as ordered. Prophylactic antibiotics may be indicated in certain high-risk premature infants to prevent early-onset sepsis.
7. Monitor for and report signs of infection promptly. Educate all staff and parents to recognize and report any signs of potential infection immediately.
8. Educate parents on infection prevention measures at home. Teach parents about hand hygiene, avoiding crowds, and recognizing signs of infection after discharge.
Conclusion
Nursing diagnoses provide a crucial framework for the care of premature infants. By recognizing the unique vulnerabilities of these infants and utilizing nursing care plans, nurses can effectively address their complex needs. Focusing on diagnoses such as Imbalanced Nutrition, Ineffective Thermoregulation, Impaired Gas Exchange, Impaired Skin Integrity, and Risk for Infection ensures a holistic and proactive approach to care. This comprehensive approach not only improves immediate outcomes for premature infants in the NICU but also sets the foundation for their long-term health and development. Continuous assessment, evidence-based interventions, and parental education are essential components of providing exceptional nursing care and optimizing the well-being of premature infants.
References
- Berman, A., Snyder, S., & Frandsen, G. (2016). Promoting Health from Conception Through Adolescence. In Kozier and Erb’s fundamentals of nursing: Concepts, practice, and process (10th ed., pp. 330-335). Prentice Hall.
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Gallacher, D. J., Hart, K., & Kotecha, S. (2016). Common respiratory conditions of the newborn. Breathe, 12(1), 30-42. https://doi.org/10.1183/20734735.000716
- Nettina, S. M. (2019). Pediatric Primary Care. In Lippincott manual of nursing practice (11th ed., pp. 3223-3224). Lippincott-Raven Publishers.
- Silvestri, L. A., & CNE, A. E. (2019). Care of the Newborn. In Saunders comprehensive review for the NCLEX-RN examination (8th ed., pp. 810-826). Saunders.
