NAME: GUERRERO, AUBREY MARIE BSN 4B

NURSING CARE PLAN FOR NUCHAL CORD (newborn)

Signs and Symptoms Impaired gas exchange At the end of 20-hour - Assess - Checking these After the 20-hour
presented: related to decrease in RLE, the patient will: respiratory rate, values provides 08/30/2022 at 9:30 RLE, goals were met
oxygen supply as depth, and information AM as:
OBJECTIVE CUES: evidenced by cyanotic - Have an breathing effort about changes
Upon observation, it appearance and low improved gas along with a that can reveal 1. Performed - Patient
was noted that the respiratory rate. exchange full set of vital respiratory EINC and obtained a RR
newborn has: evidenced by signs every compromise placed the baby of 45
- Dusky face and respiratory rate four hours and early. in the crib to breaths/min,
facial features of 30-50 as needed. ensure comfort, FHR of 155
- Blue breaths/min, - Assess the - Any safety, and bpm, and SpO2
extremities FHR of 120 – lungs for areas irregularity of keep newborn of 97%.
- Slight abrasion 160 bpm, and of decreased breath sounds away from - Patient’s
in the neck of SpO2 of 93- ventilation and may disclose disturbances. appearance
the newborn 97%. auscultate the cause of 2. Checked v/s of improved
- Weak reflexes - Display an presence of impaired gas the newborn, (Pinkish)
- APGAR score improved adventitious exchange. The FHR = 92 bpm, showing better
of 6 at 1 and 5 appearance and sounds. presence of RR = 20 oxygenation
minutes after activity crackles and breaths/min, and activity
birth. (reflexes). wheezes may SpO2= 91 %, improved
Vital Signs: alert the nurse all the rest are (better reflexes)
- FHR: 92 bpm to airway within normal showing no
- RR: 20 obstruction, values. signs of
breaths/min leading to or 3. Assessed distress.
- SpO2: 91 % exacerbating patient's
existing appearance and
- Note signs of hypoxia. noted cyanosis
 cyanosis. - Cyanosis of the in extremities
Assess skin, tongue and lips while
oral is a sign of observing
membranes, central reflexes,
and tongue for cyanosis activity, and
blue indicating sever responses to
discoloration. hypoxia and stimuli.
considered a 4. Assessed
medical patient’s
emergency. respiration
This is a late from time to
sign of time, noting
decreased rate, depth, and
- Monitor oxygenation use of effort.
oxygen and perfusion. 5. Auscultated
saturation and - These values lungs,
ABGs. Note reveal revealing no
the trend of information sign of
these values. about the adventitious
severity of the breath sounds.
patient’s
condition. At 10:00 AM
Worsening
values may be 6. Administered
a sign of supplemental
respiratory oxygen via
failure in a nasal cannula
- Monitor for deteriorating at 4-6L/min.
alteration in BP situation. 7. Administered
and HR. - BP, HR, and prescribed
respiratory rate medications.
all increase 8. Observed
with initial patient’s
reaction to
 hypoxia and medication and
hypercapnia. supplemental
However, when oxygen.
both conditions 9. Advised
become severe, mother to allow
BP and HR newborn to rest
- Decrease
decrease, and and to limit
noxious
dysrhythmias visitors as
environment
may occur. needed.
stimuli.
- To promote
better rest time 10:00 AM – 3:00 PM
for the 10. Continuously
newborn. monitored
Irritants in the patient from
environment time to time.
decrease the 11. Documented on
patient’s patient’s chart.
- Monitor the effectiveness in 12. Endorsed
newborn’s accessing patient to
level of oxygen during incoming shift.
responsiveness, breathing.
activity, muscle - These measures 08/31/2022 at 8:30
tone, and help determine AM
posture. if the brain and
- Administer nervous system 1. Checked v/s of
medications are working the newborn,
and IV fluids as well. FHR = 155
prescribed. bpm, RR = 45
- Prescribed breaths/min,
medications aid SpO2= 97 %,
in controlling BP = 64/41
- Provide chronic and mmHg.
respiratory temporary 2. Assessed
support by patient's
 giving conditions. appearance and
supplemental - Supplemental noted pinkish
oxygen. oxygen body and
improves gas extremities.
exchange and 3. Observed
oxygen improved
saturation. The reflexes,
patient may activity, and
need a nasal responses to
- Monitor for cannula to stimuli.
complications. maintain an O2 4. Observed and
saturation noted better
above 90%. respiration
- While a nuchal from time to
cord may not time, noting
always cause rate, depth, and
any problems, non0labored
it can breathing.
sometimes 5. Auscultated
cause serious lungs,
complications, revealing no
including birth sign of
injuries such as adventitious
hypoxic- breath sounds.
ischemic 6. Continuously
encephalopathy observed
(HIE) due to patient for any
lack of oxygen alterations in
during the V/s and for any
birthing untoward signs
process. and symptoms.
7. Documented
findings and
 procedures
done on
patient’s chart.

Reference/s:
Ellis, E. (2019, November 13). Nursing Care Plan for Perinatal Asphyxia. Nursing Care Plan. Retrieved August 30, 2022, from

https://free-nursingcareplan.blogspot.com/2011/07/nursing-care-plan-for-perinatal.html

Taylor, R. (2018, August 6). Birth Asphyxia Nursing Care Management. RNpedia. https://www.rnpedia.com/nursing-notes/maternal-and-child-nursing-notes/birth-asphyxia/

Young, B. (2017, September 29). How Does Nuchal Cord Affect My Baby? Healthline. Retrieved August 30, 2022, from https://www.healthline.com/health/pregnancy/nuchal-cord

Wayne, G. B. (2022, May 7). Impaired Gas Exchange Nursing Care Plan. Nurseslabs. Retrieved August 31, 2022, from https://nurseslabs.com/impaired-gas-exchange/