Nurse's Pocket Guide

N
Neglect/Abuse CH/PSY
(Refer to Abuse; Battered child syndrome)
Neonatal, normal newborn PED
risk for impaired Gas Exchange: risk factors may include prenatal or
intrapartal stressors, excess production of mucus, or cold stress.*
risk for imbalanced Body Temperature: risk factors may include large
body surface in relation to mass, limited amounts of insulating subcutaneous
fat, nonrenewable sources of brown fat and few white fat
stores, thin epidermis with close proximity of blood vessels to the
skin, inability to shiver, and movement from a warm uterine environment
to a much cooler environment.*
risk for impaired parent/infant Attachment: risk factors may include
developmental transition (gain of a family member), anxiety associated
with the parent role, lack of privacy (intrusive family/visitors).*
risk for imbalanced Nutrition: less than body requirements: risk factors
may include rapid metabolic rate, high-caloric requirement,
increased insensible water losses through pulmonary and cutaneous
routes, fatigue, and a potential for inadequate or depleted glucose
stores.*
risk for Infection: risk factors may include inadequate secondary
defenses (inadequate acquired immunity, e.g., deficiency of neutrophils
and specific immunoglobulins), and inadequate primary
defenses (e.g., environmental exposure, broken skin, traumatized tissues,
decreased ciliary action).*
Neonatal, premature newborn PED
impaired Gas Exchange may be related to alveolar-capillary membrane
changes (inadequate surfactant levels), altered blood flow (immaturity
of pulmonary arteriole musculature), altered O 2 supply (immaturity
of central nervous system and neuromuscular system, tracheobronchial
obstruction), altered O 2-carrying capacity of blood
(anemia), and cold stress, possibly evidenced by respiratory difficulties,
inadequate oxygenation of tissues, and acidemia.
ineffective Breathing Pattern/Infant Feeding Pattern may be related to
immaturity of the respiratory center, poor positioning, drug-related
depression and metabolic imbalances, decreased energy/fatigue, possibly
evidenced by dyspnea, tachypnea, periods of apnea, nasal flaring/use
of accessory muscles, cyanosis, abnormal ABGs, and tachycardia.
risk for ineffective Thermoregulation: risk factors may include immature
CNS development (temperature regulation center), decreased
ratio of body mass to surface area, decreased subcutaneous fat, limited
brown fat stores, inability to shiver or sweat, poor metabolic
reserves, muted response to hypothermia, and frequent medical/
nursing manipulations and interventions.*
risk for deficit Fluid Volume: risk factors may include extremes of age
and weight, excessive fluid losses (thin skin, lack of insulating fat,
increased environmental temperature, immature kidney/failure to
concentrate urine).*
*A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at
prevention.
866 NURSE’S POCKET GUIDE