NANDA-NursingPlan Area 11 Safety/Defense

NANDA Nursing Plan 00156 Risk for sudden infant death

Note: This article was translated from Japanese using translation software. Please use at your own risk, as there may be unnatural points in the content or differences in content due to cultural differences.


Area 11 Safety/Defense

Category 2 Bodily injury Bodily harm or injury

00156 Risk for sudden infant death

Nursing Diagnosis: 00156 Risk for sudden infant death
Definition: A condition that may result in sudden infant death.

1. What is Sudden Infant Death Syndrome (SIDS)?

What is Sudden Infant Death Syndrome (SIDS)? (See Ministry of Health, Labor and Welfare website)
https://www.mhlw.go.jp/bunya/kodomo/pdf/sids_guideline.pdf

Definition: A syndrome that causes sudden death in infants under 1 year of age, whose death cannot be predicted based on previous health status and medical history, and whose cause cannot be identified by fat status surveys and autopsy examinations.

Disease concept: Mainly occurs during sleep, and the incidence in Japan is estimated to be about 1 in 6,000 to 7,000 births. .

2. Indications for “Risk for sudden infant death”

1) Unchangeable risk

・2 to 4 months old (respiratory condition is immature)
Ethnicity (African American or Native American)
・Men raising children
・Season (autumn and winter)
・Low birth weight infant
・Young parents (lack of knowledge, lack of experience, lack of attachment to children, etc.)

Reference: Ministry of Health, Labor and Welfare “FY2018 Research Project for Promoting Support for Child and Child-Rearing Research Project for Health Guidance for Small Born Babies” https://www.mhlw.go.jp/content/11900000/000592914.pdf The burden of raising a low birth weight baby is introduced as a “family assessment item and predicted problem”. These problems suggest that caregivers may not be able to raise children in a normal state of mind.

2) Remediable risks

・Environment: placement of objects around the infant (installation of soft rugs and stuffed animals)
・How to lay down: Risk of suffocation in lateral or prone position
・Full of smoke, gas, etc.: Smoking, etc.

3. Goal setting (linkage → goal)

Goal setting by linkage (listed in the second half of the NOC)

* “Linkage” has the role of connecting “NANDA”, “NIC” and “NOC” (link means “connection”).

1) Linkage achievements

Knowledge: Infant Care (1819)
(Definition: degree of understanding of child care from birth to 1 year)

・ Parenting achieved: Infant (2904)
(Definition: Parental actions to provide a positive physical, emotional, spiritual and socially safe and nurturing environment for infants from 28 days of age to first birthday)

・Parenting Achieved: Infant Physical Safety (2900)
(Definition: Parental Actions to Prevent Physical Injury in Infants from Birth to Age 2)

・Indications for newborns (0118)
(Definition: The adaptive response of a physiologically mature neonate to the extrauterine environment during the first 28 days of life)

・Temperature adjustment: Newborn (0801)
(Definition: Balance of heat production, gain, and loss during the first 28 days of life)

Knowledge: Premature Infant Care (1840)
(Definition: Degree of understanding of caring for preterm infants born between 24 and 37 weeks of gestation)

・Risk Control: Smoking (1906)
(Definition: Individual behavior to understand, prevent, eliminate or reduce smoking-related health threats)

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do ○○”,
For example, “The patient will be able to do ○○.”

• Caregivers can make statements about infant development. In addition, child-rearing can be practiced to promote development.

・Caregivers can provide an environment for infants.

・ Caregivers can avoid factors that impede infant development.

・The caregiver can collect the information necessary for childcare while interacting with society.

*Nurse goals include:

Assuming that “improvable risks” cannot be improved, let’s take measures against “probably improveable risks” and “improvable risks”.

・Support caregivers to acquire knowledge and skills to promote the growth and development of infants.

・Encourages attachment formation between the caregiver and the child.

4. nursing plan

1 >> Observation plan (OP)

・Characteristics of normal infants (posture of limb MW, crying, sucking, reflexes, etc.)
・Normal growth and development (within the growth curve)
・Appropriate way to hold an infant ・Appropriate position of an infant
・Lactation method
・How to bathe
・How to treat the umbilical cord
・Methods for adjusting clothing to suit the environment
・Knowledge of childcare

・Relationship between infant and caregiver (whether there is affection and attachment to the infant)
・Nursing environment for infants
・Safe bedding ・Layout on the bed (whether there are stuffed animals etc.) ・Appropriate use of fences
・Do you use age-appropriate toys?
・Are there any dangerous items within reach (cigarettes, buttons, button batteries, etc.)?
・Is it not left in a car, bathroom, etc.?
・Is the ventilation sufficient? (Is the gas filled?)
・The caregiver’s approach to the infant (talking to the infant, observing the reaction, the reaction of the infant)
・ Mother’s mental state (depression, childcare fatigue, lack of support from family)
・Family composition (childcare burden by one parent, differences in childcare views due to living with mother-in-law, stress, etc.)
・Are vaccination schedules followed?
・Presence or absence of smoking by the caregiver
・How to raise infants (whether they are treated safely and cleanly)
・Presence or absence of child abuse
・Presence or absence of participation in infant health checkups
・Physical abuse ・Sexual abuse ・Neglect
・The degree of growth and development of infants

Reference: “Infant physical development evaluation manual” March 2012 FY 2011 Health Labor Sciences Research Grant (Next-generation development basic research project such as overcoming childhood diseases) https://www.niph.go.jp/soshiki/ 07shougai/hatsuiku/index.files/katsuyou.pdf provides detailed information on growth and development from infancy to school age.

・Denver Developmental Screening Test
・physical growth curve
・ Nursing amount (artificial) ・ Nursing interval
・Feeding interval for breastfeeding ・Latch-on
・Birth weight (low birth weight infants)
* Low birth weight infants refer to infants weighing less than 2,500 g at birth. Births weighing less than 1,500 g are called very low birth weight babies, and babies weighing less than 1,000 g are called very low birth weight babies.

・Gestational age (preterm infants)
* Premature babies are babies born between 22 and 36 weeks. If the baby dies in utero, it is called a stillbirth, and if it is less than 22 weeks gestation, it is a miscarriage. It is said that even low birth weight infants can survive after 22 weeks of birth, but the organs that normally mature in the mother’s body are born immaturely, and special treatment may be required in some cases.

*Ministry of Health, Labor and Welfare “FY2018 Child/Childrearing Support Promotion Research Project: Research Project on Health Guidance for Small Born Babies” https://www.mhlw.go.jp/content/11900000/000592914.pdf , explains in detail the organ underdevelopment that can occur in low birth weight babies (mostly premature babies), treatment, care, and family support.
・Apgar score
・Gestational age index
・ Coombs test:
A test to check for irregular antibodies to red blood cells. Agglutination results in irregular antibody positivity. Maternal antibodies may cross the placenta and destroy fetal red blood cells.
・Breathing rate 30-60 breaths/minute (the normal value for newborns is 30-60 breaths/minute)
Apical pulse rate of 100-160 beats/minute (Normal value of 90-180 beats/minute in neonates)
・ Nursing time
・Sucking reflex
・Response to stimulation
・Muscle tension
・Blood glucose level
・Bilirubin level ・Jaundice
・Defecation and urination

・Insufficient weight gain (beyond the range of physiological weight loss)
・Instable body temperature
・Hyperthermia/hypothermia
・Irregular breathing/tachypnea
・A restless state (restlessness), lethargy
・Changes in skin tone
・dehydration
・Instable blood sugar level
・Hyperbilirubinemia

〈Knowledge: Caring for premature babies〉
・Causes and factors of premature birth
・Appropriate baby position
Infant sleep-wake patterns
・Need for respiratory support
・Necessity of thermal adjustment
・Necessity of skin care
・The need for blood glucose monitoring
・Diagnostic imaging examination
・Nutrition method
・Kangaroo care
A reliable source of information on premature infant care
・Support group
・Discharge plan
・Parents’ attitudes toward infants

・Understanding the risks of smoking
・Harmfulness of secondhand smoke

2 >> Action plan (TP)

・Environment suitable for infants.
・Room temperature adjustment ・Bed ・Clean baby clothes and bedding
・Provide support for acquiring child-rearing skills so as to promote parent-child parenting.
・ Breastfeeding support (how to hold, latch on, how to measure the amount of breastfeeding)
・ Bathing
・Diaper change
・ Postpartum gymnastics
・Don’t work too hard on childcare. Rely on someone you can rely on.
・Sleep little by little with your baby because you can’t sleep well in the neonatal period
・Childcare support for fathers
・ How to express milk, how to store breast milk after pumping
・Perform postpartum care
· Uterine fundus massage, cleanliness care, genital treatment, pain control, etc.

3 >> Education plan(EP)

・Speak to caregivers who smoke about the effects of secondhand smoke on infants, and explain to them to separate smoking areas when smoking or to quit smoking.
・Because nicotine passes into breast milk, the patient should be instructed not to smoke while breastfeeding. Breastfeeding immediately after smoking is especially bad.
・Explain the child-rearing environment. (Don’t put anything that could cause suffocation, don’t forget the fence, etc.)
・Explain the growth and development of infants (written in maternal and child health handbooks and attachments), and explain that they should have regular health checkups.
・Explain that if you have any concerns about the growth and development of your child, you should consult with them.
• Fully explain the benefits and risks of vaccination. (Risks often outweigh benefits)
・If you notice any abnormalities in the infant after discharge (no urination, no stool, weak crying, no crying, lack of vitality due to muscle relaxation, fever, sucking milk) If the patient has a bad complexion, the eyeballs or body has turned yellow, etc.), explain that the patient should first contact the ward by phone. (Recommend seeing a doctor if necessary)
・If there is anxiety or stress about childcare after discharge, contact the ward or a support group, and explain that you will not be alone. During regular check-ups, the mother’s mental state is also monitored through preliminary questionnaires, medical examinations, and consultations with public health nurses, so you can consult there. It’s nothing to be ashamed of because everyone experiences stress.

References

T. Heather Hardman Shigemi Kamitsuru. (2016). NANDA-I Nursing Diagnosis Definition and Classification 2015-2017. Igaku Shoin.
Okaniwa, Yutaka. (2012). Review book for nurses and nursing students. Medic Media Co., Ltd.
Yutaka Okaniwa. (2019.3). Year Note 2020. Medic Media Co., Ltd.
Yuko Kuroda (Translation). (2015). Nursing Outcome Classification (NOC) Original 5th Edition Indicators and Measurement Scales for Measuring Outcomes. Elsevier Japan K.K.
Yamaguchi Toru, Kitahara Mitsuo, Fukui Tsuguya. (2012). Today’s treatment guidelines.
Yumiko Ohashi, Hajime Yoshino, Naoki Aikawa, Sumi Sugawara. (2008). Nursing Learning Dictionary (3rd Edition). Gakken Co., Ltd. (Gakken).

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