Nursing care plan

Of The newborn
 Nursing Care Plan of the newborn
Cues/Evidence Nursing Diagnosis Objective Intervention Rationale Evaluation

OBJECTIVE DATA:
Dx: NSVD with thick
meconium stain
Presence of thick (dark)
meconium during
suctioning (in nose and
mouth)
Use of mechanical
suctioning
Slight flaring ala nasi during
the P. A of newborn
Sneezing noted during
initial care
RR= 63 cpm
Newborn has faint cries
Ineffective breathing pattern
r/t aspiration of meconium
during birth
Within our care, Assess and report further Further signs and At the end of our care,
the newborn will sings of respiratory distress symptoms could lead the newborn achieved
have an effective to complications which effective breathing
breathing pattern may result to chronic pattern as evidenced
as evidenced by; hypoxia and acidosis, by;
increasing the risk of
Absence of CNS damage RR= 58 cpm fast and
respiratory shallow
distress such as Clear the newborns airway This helps remove
flaring of the ala by suctioning the mouth accumulated fluid, Flaring of the ala nasi
nasi, cyanosis, using a bulb syringe facilitates respiratory not observed anymore
dyspnea and effort and helps
abnormal breath prevent further nose and mouth were
sound aspiration free of mucus
secretions
RR should be Note the pitch and intensity Initially, a strong cry
within normal of the cry of the newborn increases alveolar good cry was initiated
range pressure of oxygen and
(30 –60cpm) produces the necessary
chemical changes to
Absence of convert fetal to
mucus secretions neonatal circulation, so
in the nose and that the heart rate
 mouth increase to 175-
180uterus
Initiation of good
cry

OBJECTIVE DATA: Risk for infection r/t immature Within our care, Monitor vital signs Determine any At the end of our care,
Dx: NSVD with thick immune system the newborn will; abnormal changes, the newborn;
meconium staining raise in temperature
Vital signs within may indicate infection Vital signs remained
Presence of thick (dark) normal range within normal range
meconium during T= 34 o C Allows recognition of Temp.= 37˚C
suctioning (in nose and PR= 120 – 160 abnormal findings and HR= 139 bpm
mouth) bpm allow prompt RR= 58cpm
RR= 30 –60 cpm intervention if
Vital signs: complication occurs Newborn is free of
Manifest no signs signs and symptoms of
Temp.= 36.8˚C
of infection like washing hands before and Hand washing is the infection such as fever
HR= 125bpm fever and chills after providing care single best way to and fatigue
avoid spreading
RR= 63cpm
pathogen Mother had fully
understood the
wearing gloves to maintain Gloves reduce the importance of
asepsis when providing possibility of breastfeeding in
direct care and when in transmitting disease relation to
contact with blood or body strengthening the
secretions immunity

Monitor WBC count above Indicates increased

11,000/mm3 production of
leukocytes by bone
marrow, usually in
response to the
presence of bacterial
pathogens

Encourage mother to begin Colostrum and breast

breastfeeding milk contain high
early if indicated amounts of
immunoglobulin A,
which provides passive
immunity and helps
reduce infection

Instilling eye ointment Instill ophthalmic drops

(gentamicin ointment) or ointment to provide
prophalaxis against
opthalmia menatorum