Nursing Care plan for APNEA
ASSESSMENT NURSING DIAGNOSIS PLAN INTERVENTION
Related to Evidenced by
*Assess the *Ineffective Breathing Possibly evidenced by *Infant/Child will *Assess airway for patency.
frequency and Pattern related to Apnea during maintain respiratory *Assess respirations. Note quality, rate,
pattern of breathing. Tracheobronchial sleep/Changes in status to baseline pattern, depth, flaring of nostrils, dyspnea
*Assess obstruction/ respiratory parameters for pattern on exertion, evidence of splinting, use of
skin, nail beds, skin, secretions/ infection depth/Pallor or rate, depth, and ease. accessory muscles, and position for
mucous membranes cyanosis breathing.
for pallor or *Assess breath sounds by auscultation.
cyanosis. *Assess cough (moist, dry, hacking,
*Assess respiratory *Impaired Gas Possibly evidenced by *infant/Child will paroxysmal, brassy, or croupy): onset,
rate, depth, and Exchange related to Apnea demonstrate improved duration, frequency, if it occurs at night,
ease, periods of Ventilation-perfusion Bradycardia gas exchange and during day, or during activity; mucus
apnea. imbalance Hypercapnia arterial blood gases will production: when produced, amount, color
*Assess infant for Preterm birth maintain within normal (clear, yellow, green), consistency (thick,
skin color and Hypoxia ranges for age. tenacious, frothy); ability to expectorate or
perfusion. Pallor if swallowing secretions, stuffy nose or
nasal drainage.
*Monitor ABG levels
*Elevate head of bed at least 30° for child
and oxygen
and hold infant and young child in lap or in
saturation
an upright position with head on shoulder;
*Assess family *Compromised Possibly evidenced by *Family members will older child may sit up and rest head on
anxiety level, erratic Family Coping Family expresses be able to express a pillow on over bed table.
behaviors (anger, related to concern feelings and needs to
tension, and fear about *Assist to perform deep breathing and
Situational crisis each other.
disorganization) infant’s apnea coughing exercises in child when in a
*Family members
perception of crisis episodes relaxed position for postural
identify three healthy
situation. Displays protective drainage unless procedures are
coping mechanisms.
*Assess family’s behavior contraindicated; use incentive spirometer
previous coping disproportionate to in older child, blowing up balloon, blowing
methods and infant’s need to bubbles, blowing a pinwheel or blowing
perceived grow and develop cotton balls across the table in younger
effectiveness. Describes a child.
preoccupation with *Assess pulse rate and oxygen saturation
monitoring of using pulse oximetry.
infant apnea, *Monitor blood gases.
chronic anxiety *Maintain a clear airway by encouraging
patient to mobilize own secretions with
successful coughing.
ASSESSMENT NURSING DIAGNOSIS PLAN INTERVENTION
Related to Evidenced by
*Assess the *Ineffective Breathing Possibly evidenced by *Infant/Child will *Assess airway for patency.
frequency and Pattern related to Apnea during maintain respiratory *Assess respirations. Note quality, rate,
pattern of breathing. Tracheobronchial sleep/Changes in status to baseline pattern, depth, flaring of nostrils, dyspnea
*Assess obstruction/ respiratory parameters for pattern on exertion, evidence of splinting, use of
skin, nail beds, skin, secretions/ infection depth/Pallor or rate, depth, and ease. accessory muscles, and position for
mucous membranes cyanosis breathing.
for pallor or *Assess breath sounds by auscultation.
cyanosis. *Assess cough (moist, dry, hacking,
*Assess respiratory *Impaired Gas Possibly evidenced by *infant/Child will paroxysmal, brassy, or croupy): onset,
rate, depth, and Exchange related to Apnea demonstrate improved duration, frequency, if it occurs at night,
ease, periods of Ventilation-perfusion Bradycardia gas exchange and during day, or during activity; mucus
apnea. imbalance Hypercapnia arterial blood gases will production: when produced, amount, color
*Assess infant for Preterm birth maintain within normal (clear, yellow, green), consistency (thick,
skin color and Hypoxia ranges for age. tenacious, frothy); ability to expectorate or
perfusion. Pallor if swallowing secretions, stuffy nose or
nasal drainage.
*Monitor ABG levels
*Elevate head of bed at least 30° for child
and oxygen
and hold infant and young child in lap or in
saturation
an upright position with head on shoulder;
*Assess family *Compromised Possibly evidenced by *Family members will older child may sit up and rest head on
anxiety level, erratic Family Coping Family expresses be able to express a pillow on over bed table.
behaviors (anger, related to concern feelings and needs to
tension, and fear about *Assist to perform deep breathing and
Situational crisis each other.
disorganization) infant’s apnea coughing exercises in child when in a
*Family members
perception of crisis episodes relaxed position for postural
identify three healthy
situation. Displays protective drainage unless procedures are
coping mechanisms.
*Assess family’s behavior contraindicated; use incentive spirometer
previous coping disproportionate to in older child, blowing up balloon, blowing
methods and infant’s need to bubbles, blowing a pinwheel or blowing
perceived grow and develop cotton balls across the table in younger
effectiveness. Describes a child.
preoccupation with *Assess pulse rate and oxygen saturation
monitoring of using pulse oximetry.
infant apnea, *Monitor blood gases.
chronic anxiety *Maintain a clear airway by encouraging
patient to mobilize own secretions with
successful coughing.
