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Nursing Diagnosis:

Ineffective Thermoregulation R/T newborn transition to extrauterine life


Ineffective Thermoregulation R/T immature compensation for changes in environmental temperature.

High Risk for infection R/T maturational factors, immature immune system
Risk for Infection R/T break in skin integrity at umbilical cord site

Risk for Altered Nutrition (more or less than body requirements) R/T (insufficient caloric intake or excessive
caloric intake)

Ineffective Airway Clearance R/T excessive oropharyngeal mucus

Prevent infection:
handwashing, stay away from large groups or ill individuals, prophlactic agents (EES, cord care, bathing)
Vernix
Breastfeeding

Warmth
Bath after temperature is stable
warmer/isolette/bundle
hat
keep out of drafts
skin to skin

Position of sleep/prevent SIDS


Back to sleep
feet to foot of bed
no stuffed animals or excessive blankets in bed
don’t cover head in stroller
don’t keep house too warm
No smoking around infant

Cleanliness
No tub baths until cord off and healed
clean around organs of elimination and mouth after soiling to prevent skin break down
daily head to toe bath not necessary
OK to clean and touch the “soft spot”
fold diapers away from umbilicus
NEVER leave child alone in tub!!

Circumcision-After Care
keep wound clean and dry (warm water)
ck urination w/in 12 hrs after procedure
monitor for bleeding
s/s of infection will not occur immediately after procedure

Diagnosis
IMPAIRED GAS EXCHANGE related to inadequate surfactant levels; as evidenced by grunting, flaring, substernal
and intercostal retractions, CO2 50 and pH 7.31 per CBG and CXR with ground glass appearance suggestive of
hyaline membrane disease.
I
- Administered warmed and humidified oxygen at rate ordered per oxyhood, wean slowly to room air as ordered.
- - Monitor and document hourly Fi)2 levels per calibrated O2 analyzer. Sa)2 per pulse oximeter, and vital signs
(temperature, heart rate/rhythm, respiratory rate and effort).
- - Auscultate lung fields hourly and assess respiratory effort hourly, cyanosis, grunting, flaring or retracting and
activity.
- - Maintain gastric decompression per oral gastric tube open to air, perform oral/nasal suctioning and chest
physiotherapy as ordered.
- - Maintain temperature in normal range and schedule nursing interventions to help newborn minimize stress,
conserve energy, and reduce oxygen requirements.
- - Assess hourly for continued improvement and readiness to wean from oxygen therapy, as well as, signs of
worsening condition.
INEFFECTIVE THERMOREGULATION related to prematurity and low birth weight; as evidenced by poor flexion
and lack of subcutaneous fat stores needed for non shivering thermogenesis.
I
-- Provide neutral thermal environment per radiant warmer with temperature probe secure and in anterior position
to newborn.
- - Protect newborn from loss of body heat from conduction, convection, radiation, and evaporation.
- - Cover warmer bed over infant's chest and lower body with saran wrap to prevent insensible fluid loss and
drafts.
- - Monitor axillary temperature hourly and adjust settings on warmer as needed to maintain temperature of 97.8
to 98.8 F.
- - Warm and humidify oxygen being delivered to newborn.
ALTERED NUTRITION: LESS THAN BODY REQUIREMENTS related to respiratory distress; as evidenced by
confinement under oxyhood, oral gastric tube to drainage, respiratory rate greater than 60 per minute, and NPO
status
I
- - Provide IV fluids, D10W for hydration and glucose while newborn is under oxyhood.
- - Assess need for parenteral nutrition if oxygen therapy is longer than 12 hours.
- - When respiratory status has stabilized begin feeding newborn D5W to assess tolerance to oral feedings. Begin
formula feedings after two glucose water feedings.
- - If newborn does not have a strong sucking, gag, or swallow reflex or is at risk for aspiration, provide feedings
through a nasogastric (NG) tube.
- - Monitor glucose levels hourly until stable, each four hours times two, then every eight hours while on IV fluids.