NURSING CARE PLAN

ASSESSMENT Subjective: Objective: - cyanotic -APGAR score of 6 -poor reflex -suction -poor breathing -to prevent aspiration DIAGNOSIS Respiratory Distress related to the mother wasnt able to bear down correctly. PLANNING After nursing intervention the baby will be able to promote normal breathing pattern and reduce possible aspiration. INTERVENTION -monitor vital signs. RATIONALE -serves as baseline data. -to promote movement and crying. EVALUATION After nursing intervention the baby was able to promote normal breathing pattern and reduce possible aspiration.

-back rubbing and massaging the baby.

-Position the baby in trendelenburg and side lying position.

-to let the secretions out and prevent aspiration.

Avila, Lyka M. BSN 3

NURSING CARE PLAN

ASSESSMENT Subjective: No Cues Objective: -Temp: 35.2 C -cool and pale extremities -newborn exposure to cool environment -Not fully developed thermoregulation. -conduction ( the warm body heat transfers to cooler objects that they come into direct contact with ) -evaporation from exposure of wet skin surfaces lost to the atmosphere. -convection ( the body heat transfers DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Risk for hypothermia related to immaturity of newborns temperature regulatory system as manifested by:
-Temp: 35.2 C -cool and pale extremities -newborn exposure to cool environment -Not fully developed thermoregulation.

After nursing intervention the patients temperature will be reached within normal range.

-monitor temperature.

-regular temperature monitoring will identify adequate or inadequate thermoregulation. -to warm the newborn and adequately maintain accepted thermal range.

After nursing intervention the objective was met and the patients temperature was reached within normal range.

-provide heat/warm the newborn using incubators, radiant warmer and skinto-skin contact. -maintain thermal neutral environment and avoid situations that might predispose the infant to heat loss, such as cool air, bathing and cold bedding. -dry the newborn thoroughly and

-to maintain stable body temperature of the newborn and decrease the possibility of heat loss through conduction, convection, radiation and evaporation. -drying quickly and placing on a

to the air surrounding them ) -radiation ( the warm body heat transfers to cooler objects around them )

place the infant under pre warmed radiant warmer.

warm, dry surface prevent heat loss from evaporation.

Avila, Lyka M. BSN 3