Intermediate or Neonatal Intensive Care Nursery (ICN or NICU)

CLINICAL LOCATION

Refer to clinical orientation and schedule for details.

PREPARATION GUI DELI NES

1. Review theory content for the care of high-risk infants
2. Prepare Teaching Project

LEARNING OBJECTIVES

1. Evaluate the role of the nurse in the ICN.
2. Identify the common procedures used in caring for the high ri sk neonate.
3. Assess the special needs of the premature infant, meconium 1spiration infant, the infant suffering
from intrauterine or birth asphyxia, the drug dependent infant
4. Participate in the care of a high-ri sk infant (assessment, feeding, etc.)
5. Observe and discuss the role parents can assume and the teaching and support needs they have.

ACTIVITIES


Observe and participate in the care of a high risk neonate.
Observe and develop a beginning understanding of the rationale for care provided each infant in
the ICN.

Assignments

1. Present your selected teaching project to the clinical group during post conference of your ICN
day. Tum in your pamphlet and outline.
2. Post one response and respond to another student's posting in the corresponding course website
discussion forum before your next clinical experience.

VS: T
p
R BP 02Sat

Diet

Intake

Method

PO




NG

Output


BM

Type

Current weight
Growth percentile


Supplemental 02

Meds

Method

scheduled


c
NICU Shift Report


Student Nurse Name:-----------

DOB
GA at birth Corrected GA
Diagnosis
Brief history




Assessment abnormals:






Gender








Pain





Void



1/min
PRN







Labs/x-rays




Plan/ interventions

er
LMP: EDB:
G
p
(T P A L

Student name: _
ICN/NICU Care Plan

Date: -------------------

For one patient, provide some basic information about the prenatal history, Ibor and delivery process, and any
identifiable risk factors. Obtain and review lab values, and compare with the ormal values for each test. Describe the
implications of the labs in caring for this mom. Focus on anticipatory thinking ... what about her history is significant
for her labor and delivery, what about her labor and delivery is significant for er during the postpartum period and for
her newborn?



Prenatal care started @, weeks gestation
Date of birth: I

time :
Obstetric history Birth Gender : male:
date:.
female:





Problems/risk factors this pregnancy:
Gestational Age at Birth: wks
Correc ed Gestational Age: wks
What t Ipe of birth?
What did your patient take for pain during labor:

Rupture of mem , rane (ROM): date: time..:,_




Course of current admission

Birth wt :

FOG:




Length:
Chest::
1< SRC M 1< Clear
* ARC M * Meconium
Current assess ment (refer to your computer documentation)
Neuro:
Growth %tile: Wt. gain/loss?


Diagnosis :




Pathophysiology (simple terms):





Family assessment (SES, family dynamics, language , etc.):





VIS@ T P R BP Pain
02 Sats. S-hr 1, 8-hr 0 _
Cardio:



Respiratory :



Gl:



GU:



Musculoskeletal :



Integumentary :



Diet:




Pertinent labs/diagnostics Pt Test
Results
Normal
Value
What do these esults mean to you in caring for this baby?
Medication Worksheet (all scheduled medications) Pt's weight toe ay :
Medication, dose , frequency , route (if Safe dosage range for Drug type , w y ordered Side
effects IV- recommended dilution and rate) patient

















































I









'
Nursing Process
Develop appropriate nursing diagnoses based on your patients' risks, identified problems, and your assessment Use 3-part format
(ND, r/t, AEB) . Your care plan should reflect your patient's individualized needs- do not submit "canned" or
standardized care plans.

#1 - Most significant neonatal problem
Nursing Diagnosis (in appropriate format):




Measurable, Expected Patient Outcome wrfarget date:



Measurable, Expected Patient Outcome for your shift (may be the same):


Nursing Interventions (4, only one of which is assessment): Rationale (1 for ach intervention):









Outcomes Achieved/Not Achieved ; Evaluation:



Changes/Additions needed:



#2- Next most significant neonatal and/or family problem
Nursing Diagnosis (in appropriate format):




Measurable, Expected Patient Outcome wrrarget date:



Measurable , Expected Patient Outcome for your shift (may be the same) :

Nursing Interventions (4, only one of which is assessment):









Outcomes Achieved/Not Achieved; Evaluation:



Changes/Additions needed:
Nursing Interventions (4, only one of which is assessment):

The criterion used in grading care plans reflects the expectation of complet and accurate information appropriate
to your patient's history and assessed needs.

CARE PLAN CRITERIA
Perinatal & Birth History
0 Assessment complete and correct , using appropriate terminology (!> 1 element mi sing/incorrect)
0 Incomplete/inaccurate data, inappropriate terminology (2-4 elements)
0 Unsatisfactory/inaccurate data (5 or more elements)
Neonatal Admission Data
0 Data is complete and correct , using appropriate terminology (!> 1 element missing incorrect)
0 Incomplete/inaccurate data, inappropriate terminology (2-4 elements)
0 Unsatisfactory/inaccurate data (5 or more elements)
Neonatal Assessment
0 Assessment complete and correct, using appropriate terminology (!> 1 element mi sing/incorrect)
0 Incomplete/inaccurate data, inappropriate terminology (2-4 elements)
0 Unsatisfactory/inaccurate data (5 or more elements)
Diagnostics, Labs, Medications
0 Dat a complete and correct with analysis of risk factors (!> 1 element missing/incorr ect)
0Incomplete/inaccurate data,(2-4elements)
0 Unsatisfactory/inaccurate data (5 or more elements)
Communication/Documentation
0 Notation provides complete, concise picture of patient history and current status
0 Notation is vague, wordy, or incomplete
0 Notation is inadequate, providing insufficient information about patient history or current status
Care Planning (First Diagnosis)
0 Diagnosis appropriate, outcome and interventions appropriate to diagnosis, evaluation addresses expected outcome
0 Diagnosis not directly r/t patient, "canned" diagnosis, or expected outcome and evaluation don't correlate
0 Inappropriate diagnosis, incomplete,doesn't follow appropriate format
Care Planning (Second Diagnosis)
0 D i a g n o s i s appropriate, outcome and interventions appropriate to diagnosis, evaluation addresses expected outcome
0 Diagnosis not directly r/t patient, "canned" diagnosis,or expected outcome and evaluation don't correlate
0 Inappropriate diagnosis,incomplete,doesn't follow appropriate format
Presentation: spelled correctly, neat, legible, well organized
0 Legible, spelled correctly, minimal corrections, no overwritten elements (follows charting guidelines)
0 Mi s s pel l i ngs , illegible words or scribbles making the page difficult to read & follow (2-4 elements)
0 Misspellings, illegible words or scribbles (5 or more elements)


CARE PLAN GRADE:
COMMENTS:
Excellent Pass Redo