Professional Documents
Culture Documents
Current Medication
Name
(generic & brand name)
Classification
Dosage
Action
Zidovudine (Retrovir)
Nucleoside Reverse
Transcriptase Inhibitors
PO 12mg/1.2mL syrup
Q12 hours at 10 oclock
Nursing Implications
Assessment
(Supporting data)
Nursing Diagnosis
(NANDA diagnostic statement)
Nursing Interventions
(Strategies or actions for care)
Evaluation
(Clients response to nursing actions
& progress toward achieving
goals & outcomes)
1.
Infant will
maintain its body
temperature
between 97.0
and 99.0F for
entire shift
1.
o
Objective: Baby Bs axilla
temp: 97.8 F; skin warm and
dry
2.
Verbalize
understanding of
individual risk
factors and
appropriate
interventions.
2.
3.
1
Demonstrate
behaviors for
Assess infants
temp each hour.
If temp is above
101F, take
measures to bring
temp to normal
range:
Administer
antipyretics as
ordered
Monitor and
document related
symptoms with
specific regard to
febrile seizures
Monitor/maintain
comfortable
ambient
environment.
Provide
heating/cooling
measures as
indicated.
If temp is < 97.0F,
take measures to
bring temp to
normal range:
place infant under
warmer
or on mothers
chest under blanket
3.
Review potential
monitoring and
maintaining
appropriate body
temperature.
4.
5.
Mother will be
able to return
demonstrate
understanding of
kangaroo care
and other
methods of
warming baby, as
well as
demonstrate her
ability to assess
babys axillary
temperature by
discharge.
Infant will
maintain
respiratory rate
and normal
thermoregulation
patterns.
problem/individual
risk factors with
client/ SO(s).
Instruct in
measures to protect
from identified risk
factors.
4.
5.
Assessment
(Supporting data)
Subjective:
MOC states I do not want to
breastfeed my baby because I
do not want to risk her getting
infected
Nursing Diagnosis
(NANDA diagnostic statement)
1.
Minimizing the
risk of vertical
transmission of
HIV
1.
2.
Recognizing
neonatal HIV
infection early
2.
Virologic tests
allow early
diagnosis of HIV
infection
3.
Preventing
opportunistic
infections
3.
Closely monitor
infant until age 18
months to
completely rule out
HIV infection
Objective:
Baby L is consuming 20-30 mL
of formula per feeding; Babys
weight has remained constant
since birth (6 lb, 11 oz)
Nursing Interventions
(Strategies or actions for care)
4.
Addressing
psychosocial
issues
4.
Six weeks of
neonatal
zidovudine therapy
Laboratory
monitoring,
screening for
perinatal
infections,
Evaluation
(Clients response to nursing actions
& progress toward achieving goals
& outcomes)
Prophylaxis for
Pneumocystis carinii
pneumonia should be
initiated when HIV-exposed
infants are six weeks old
and should be continued for
at least four months,
regardless of negative
virologic tests, because P.
carinii pneumonia is often
the initial presentation of
HIV infection in infants.
Reference:
http://www.aafp.org/afp/200
2/0515/p2049.html
5.
Parent teaching
5.
appropriate social
support, and other
modifications of
standard infant care
Let the parents
know everything
the baby is going
through to prevent
HIV and why.