4 Apnea Nursing Care Plans

March 13, 2018

Apnea is defined as periodic cessation of breathing for more than 15 seconds in the full-term or more than 20 seconds in the preterm infant. It may be related to sepsis, gastroesophageal reflux, metabolic abnormality, seizure disorder, trauma or the impairment of breathing during sleep, although it is not uncommon to find no apparent causative factor.

Apneas in a preterm infant may be central, obstructive or mixed. In central apnea, there is a loss of chest wall movement due to the depressed respiratory center in the brain, while obstructive apnea is caused by pharyngeal collapse, neck flexion or nasal obstruction. Mixed apneas involve a central apnea that is directly followed by an obstructive apnea.

Apnea occurs during infancy and is usually resolved by one year of age without resulting in the death of the infant. The apparent life-threatening event (ALTE) that is indicative of apnea is not considered a cause of SIDS (sudden infant death syndrome), although the infant with apnea is at slightly higher risk. Both apnea and high-risk SIDS infants may be monitored by an apnea-monitoring device as a preventive measure.

Nursing Care Plans

Nursing care plan for sleep apnea is directed at supporting the infant’s cardiopulmonary status, improvement in gas exchange and breathing pattern, attainment of an optimal level of parental coping, knowledge on the treatment program and home care, and absence of complications.

Here are four (4) nursing care plans and nursing diagnosis for sleep apnea:

Ineffective Breathing Pattern

Ineffective Breathing Pattern: Inspiration and/or expiration that does not provide adequate ventilation.

May be related to

Impaired regulation

Possibly evidenced by

Apnea during sleep
Changes in respiratory depth
Pallor, cyanosis

Desired Outcomes

Infant/Child will maintain respiratory status to baseline parameters for pattern rate, depth, and ease.

Nursing Interventions	Rationale
Assess the frequency and pattern of breathing; Observe presence of apnea and changes in the heart rate.	Infants with apnea have periods of cessation of breathing over 15-20 seconds accompanied by bradycardia.
Assess skin, nail beds, skin, mucous membranes for pallor or cyanosis.	Reveals presence of hypoxemia causing cyanosis from an uneven distribution of gases and blood in the lungs, and alveolar hypoventilation caused by airway obstruction and absence of chest wall movement.
Place infant on an apnea monitor and pulse oximeter.	Identify changes in the chest movement, heart rate, and oxygen saturation caused by apnea.
Position the infant’s head and neck in neutral position.	If the neck bends too far forward or backward, blockage of breathing can happen.
Avoid prolonged suctioning; Discourage taking rectal temperatures and tube feedings.	Vagal stimulation may cause bradycardia, triggering apneic episodes.
Provide tactile stimulation by applying gentle rub in the soles of feet or chest wall	Indicated for mild and intermittent episodes of apnea to stimulate spontaneous breathing.
Administer methylxanthines (e.g., (theophylline, caffeine) as prescribed.	Used as a smooth muscle relaxant and a cardiac muscle and central nervous system stimulant.
Use of Nasal Continuous positive airway pressure (CPAP).	Indicated when the infant remains to have episodes of apnea despite producing a therapeutic level of methylxanthine.

Impaired Gas Exchange

Impaired Gas Exchange: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.

May be related to

Ventilation-perfusion imbalance

Possibly evidenced by

Apnea
Bradycardia
Hypercapnia
Preterm birth
Hypoxia
Pallor

Desired Outcomes

infant/Child will demonstrate improved gas exchange and arterial blood gases will maintain within normal ranges for age.

Nursing Interventions	Rationale
Assess respiratory rate, depth, and ease, periods of apnea.	Reveals respiratory effort, rate and depth (baselines or deviations) which affect the amount of air that reaches the alveoli for ventilation process and diffusion of oxygen (external respiration).
Assess infant for skin color and perfusion.	Apnea can cause tissue hypoxia leading to poor tissue perfusion with resulting in changes in skin color.
Assess for changes in consciousness, the presence of irritability and somnolence.	Reveals state of hypoxia as the level of oxygen in the blood decreases, results in impaired oxygenation in the brain.
Monitor ABG levels and oxygen saturation.	Monitors hypoxia and respiratory function for pO2 and pCO2 changes resulting from an abnormal ventilatory drive.
Monitor chest-Xray studies for further evaluation.	Reveals a presence of respiratory infection affecting gas exchange.
Administer continuous nasal airflow or CPAP via a nasal mask, or a face mask.	Continuous positive airway pressure (CPAP) is administered for preterm-birth apnea thought to be related to collapse of the airway.
Administer methylxanthines as indicated.	A drug used to stimulate spontaneous respiration.
Prepare infant for assisted mechanical ventilation as indicated.	Used when drug therapy and CPAP have been ineffective.
Educate the parents on the use of apnea monitor and allow for a return demonstration of application, to setting, alarms, power source, inform of when and how to respond to changes in respiration and heart rate.	Signals parents on the presence of prolonged periods of apnea in order avoid hypoxia and possibly death.

Compromised Family Coping

Compromised Family Coping: A usually supportive primary person (family member, significant other, or close friend) insufficient, ineffective, or compromised support, comfort, assistance or encouragement that may be needed by the individual to manage or master adaptive tasks related to his or her health challenge.

May be related to

Situational crisis

Possibly evidenced by

Family expresses concern and fear about infant’s apnea episodes
Displays protective behavior disproportionate to infant’s need to grow and develop
Describes a preoccupation with monitoring of infant apnea, chronic anxiety

Desired Outcomes

Family members will be able to express feelings and needs to each other.
Family members identify three healthy coping mechanisms.

Nursing Interventions	Rationale
Assess family anxiety level, erratic behaviors (anger, tension, disorganization) perception of crisis situation.	Identifies information affecting the ability of the family to cope with infant apnea and monitoring.
Assess family’s previous coping methods and perceived effectiveness.	Recognizes the need to come up with new coping skills if presently methods are inefficient in changing exhibited behaviors.
Assist family to identify and use 3 techniques to cope with and solve problems and gain control over the situation.	Provides support for problem-solving and handling of the situation.
Encourage verbalization of feelings and provide accurate information about infant apnea.	Lessens anxiety and improves family’s understanding of the condition.
Educate parents that over-protective behaviors may affect infant growth and development.	Enhances family understanding of the condition and adverse effects of behaviors.
Reinforce appropriate coping behaviors.	Promote changes in behavior and adaptation to infant care during apnea.
Reinforce need to sustain the health of family members and social contacts.	Provides knowledge about chronic anxiety, fatigue, and isolation as result of infant care and about their effects on health and care capacities of family.

Risk for Altered Parenting

Risk for Altered Parenting: At risk for the inability of the primary caretaker to create, maintain, or regain an environment that promotes the optimum growth and development of the child

May be related to

[not applicable]

Possibly evidenced by

Verbalization of role inadequacy
Request for information about parenting skills and infant care
Inappropriate caretaking behaviors (use of apnea monitoring device, cardiopulmonary resuscitation)

Desired Outcomes

Parent will verbalize readiness in handling infant during apneic episodes.
Parent will demonstrate accurate application and operation of apnea monitor.
Parent will become skillful in performing cardiopulmonary resuscitation (CPR) in the infant.

Nursing Interventions	Rationale
Assess history of apnea, sudden infant death syndrome (SIDS), life-threatening event of infant in the family.	Shows risk factors associated with the condition as support for additional assessment.
Assess for presence of apneic episodes, bradycardia, cyanosis, gastroesophageal reflux, upper respiratory infection, poor feeding with choking during feedings.	Recognizes apneic episodes of more than 15 seconds in preterm or more than 20 seconds in full-term infant, related risk factors, or possibility for SIDS and need for evaluation.
Assess parents’ ability to take part in apnea monitoring and to learn CPR as an intervention in case of an episode.	Fear and anxiety are common to parents of an apneic infant; feelings of guilt and inadequacy, fear of death of child displays a hindrance to learning and interventions needed for child’s survival.
Encourage parents to verbalize feelings about unmet needs and ability to meet and develop self-expectations.	Identifies potential for isolation and social deprivation of mother, strategies to accomplish realistic expectations.
Provide a calm, supportive and positive environment; encourage and commend positive parental behaviors.	Decreases stress and anxiety for enhanced learning of infant care procedures.
Encourage touching and play activities between parents and infant.	Strengthens bonding process and positive parental behaviors.
Provide parents with step-by-step procedures in written or picture form about apnea monitoring and resuscitation.	Provides reference as reinforcement of learning.
Teach parents safety issues of home apnea monitoring: unplugging power cord when the cord is not unplugged to monitor; removing leads from infant when not attached to monitor; using safety covers on electrical outlets to discourage siblings from inserting other objects.	Avoids electrical-related accidents to home monitor.
Demonstrate for parents, and allow for return demonstration on how to attach electrodes to belt and monitor, apply belt to infant’s chest, turn monitor on, set the monitor, test the monitor alarms, remove and care of monitor after use.	Apnea monitor use at home may be prescribed by physician for apneic and “near-miss” infants, although use is controversial; monitors cardiac and respiratory activity with an alarm system that alerts parents when rates are not within prescribed settings; electrodes, lead wires, and cable pick up on breathing and heart activity signals and limit apnea time by sounding alarm.
Instruct other significant others and support persons as to care for the child with a home monitor, including CPR.	Promotes positive coping as parents can decrease continuous responsibility of home apnea monitoring.
Demonstrate for parents and allow for return demonstration of CPR on infant model; instruct both parents and a family member in the assessment of infant and need for CPR, correct mouth-to-mouth and cardiac compression techniques; supply written and pictorial instructions or booklet for review.	Cardiopulmonary resuscitation (CPR) is indicated to resuscitate infant with cessation of breathing and presence of cyanosis.
Provide positive appraisal and support for parents as they learn to use the monitor and develop skill in CPR.	Positive reinforcement and support help the parents develop new parenting skills and feel confident in their abilities as parents.
Instruct parents to place healthy infants on their back during sleep; Avoid pillows or soft mattresses in the crib.	Decreases the risk of SIDS, according to research; the American Academy of Pediatrics recommends that healthy infants be placed on their backs to sleep. Infants placed on their sides may roll to the prone position.
Explain the difference between apnea and Sudden infant death syndrome (SIDS).	Parental perception of the relationship between these conditions is often the basis for their fear of child’s possible survival.
Suggest referral to home care agency, contact with family members and friends, other support services.	Provides a range of support and assistance, which helps to reduce anxiety and promote social activities.