NCP: ESSENTIAL NEW BORN CARE

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective breathing After 30 minutes of INDEPENDENT: After 30 minutes of
n/a pattern related to nursing interventions,  Asses RR and  Assessment nursing interventions,
immature neurologic and the infant will pattern provides goal is partially met. The
Objective: delayed pulmonary experience an effective information infant experienced an
-Preterm birth (34 weeks development breathing pattern as about neonate’s effective breathing
and 2 days) manifested by: ability to initiate pattern as manifested by:
-With oxygen hood and sustain an
regulated at 10 liters per - Infant’s RR is effective - Infant’s RR was
minute between 40-60 breathing between 40-60
-RR: 58 cycles/min - Infant will pattern. - Infant will
-Episodes of apnea (6-10 experience no  To provide  Assistance helps experience less
seconds) apnea respiratory the new born by episodes of
-O2 saturation of 91% assistance as clearing the air apnea
needed (oxygen way and
hood) promoting
oxygenation.
 Position infant  Lying on the
on side with side position
rolled blanket facilitate
behind his back breathing
 Provide tactile  Stimulation of
stimulation the sympathetic
during periods nervous system
of apnea increases
respiration.
NCP: ESSENTIAL NEW BORN CARE

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective After 24 hours of INDEPENDENT: After 24 hours of
“My baby had a fever thermoregulation related thorough nursing  Assess vital  Hypothermia nursing interventions
since yesterday, until to prematurity as intervention the infant signs, especially predisposes infant and of close
now” evidenced by poor will exhibit thermal temperature. to cold stress, monitoring, goal was
as verbalize by the flexion and lack of homeostasis appropriate utilization of non- met. Infant was able
patient’s mother subcutaneous fat for age = 36.5 - 37°C renewable brown to establish
(axillary) fat stores. normothermia and
Objective: Hyperthermia had a temperature of
Temperature: 35°C causes further 36.5°C.
Tachypnea respiratory
depression instead
of increased RR
leading to apnea
and reduced O2
uptake.
 Place infant in a  Maintain thermo
warmer, neutral
incubator, or environment, helps
open bed with prevent cold stress.
radiant warmer
or open crib
wherein infant
also has
appropriate
clothing.
 Use heat lamps  Decreases heat loss
during certain to the cooler
procedures and environment of the
warm objects room.
coming in
contact with the
infant’s body
such as clothing.

COLLABORATIVE:
 Provide or  Helps prevent
administer seizures associated
medications as with hyperthermia
prescribed. and hypothermia.
NCP: ESSENTIAL NEW BORN CARE

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective After 1 hour of nursing INDEPENDENT: After 1 hour of
n/a thermoregulation intervention, the infant  Monitor the  To determine the nursing intervention,
related to immaturity will maintain normal neonate’s body need for the goal is fully met.
Objective: and lack of body temperature from temperature intervention and The neonate will
- Gestational age subcutaneous and 36.5 – 37.5 until discharge. effectiveness of maintain normal body
of 34 weeks 2/7 brown fat therapy. temperature from
- Current weight:  Nurse will take  Dry newborn  Drying quickly and 36.7°C as evidenced
2.0 kgs. steps to maintain thoroughly and placing on a warm, by:
neonate’s body quickly and dry surface to
Integumentary status: temperature at discard the wet prevent heat loss - Nurse kept
- Pale legs, normal level, blanket. Place from evaporation. neonate’s
moderate pallor patient will have the infant under body
- Cool and dry a warm, dry skin a pre warmed temperature
skin radiant warmer. at normal
 Parents will level
Turgor: express  Avoid placing  Cold surface and - Neonate has
- less than 3 understanding of infant on cold instrument increase warm and dry
seconds neonate’s surface or using heat loss by skin
- Neonate is thermoregulatory cold instrument conduction.
placed in the disturbance and in assessment
isolation room thermoregulation.
 Ambient  To prevent
Temperature: 35.5°C temperature of excessive cooling.
- Mild shivering the room where
- Baby is placed the newborn is
in an extended kept should be
position monitored
- Poor muscle
tone  Wrap and use  Helps conserve
Labs: thick blankets to heat in the body
 Increased cover the patient
hemoglobin
(198 g/l)  Teach the  The infant’s head
 Increased mother about the provide a large
hematocrit (0.58 infant’s need for surface area for
g/l) warmth and to heat loss
 Increased WBC keep the infant’s
(10.3 x 10 d/l) head covered

 Teach family  Careful teaching

members about: allows family
members to take an
- Signs and active role in
symptoms of maintaining the
altered body neonate’s health.
temperature,
such as cool
extremities
- Factors in home
that contribute
to neonatal heat
loss and ways to
minimize heat
loss
- Importance of
contacting a
health care
provider when
problems related
to temperature
regulation.
NCP: LEOPOLDS MANEUVER

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Impaired fetal gas After hours of nursing  Assess vital  Provides baseline After hours of nursing
n/a exchange related to intervention, the patient signs 15 minutes data on the interventions, goal
altered blood flow and will verbalize maternal blood loss was met. The patient
Objective: decreased surface area understanding of  Maintain bed  Systematic rest is was able to verbalize
- Changes in fetal of gas exchange at the causative factors and rest or chair rest mandatory and understanding the
heart rate or site of the placental appropriate interventions when indicated. important causative factors and
activity detachment Provide frequent throughout all appropriate
- Release of rest periods and phases to reduce interventions.
meconium uninterrupted fatigue and
- Slight change in night time sleep. improve strength.
vital signs
except for the  Monitor amount  Provide objective
BP and type of evidence of
bleeding. bleeding.

 Position the  To promote

mother on left placental perfusion.
side.

 Restrict vaginal  Prevents tearing of

examination. placenta if placenta
previa is the cause
 Monitor fetal of bleeding.
contractions and
fetal heart rate
by external
monitor.

 Monitor positive
attitude about
fetal outcome.
NCP: LEOPOLDS MANEUVER

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Imbalance nutrition less After 5 days of nursing  Monitor vital  To obtain baseline Goal met.
n/a than body requirements intervention the patient signs data
related to prematurity will experience After 5 days of
Objective: as evidenced by progressive weight gain nursing intervention
Height& Head extreme low birth as evidenced by: the patient
circumference weight at 10th percentile  Monitor intake  To assess if there’s experienced weight
at birth. -Weight gain and output an occurring fluid gain.
- Weight: and electrolyte
- The imbalance
measurement of
the fundus is
smaller than the  Provide diet  to reveal possible
expected modifications, causes of changes
measure for the as indicated that could be made
corresponding example in client’s intake
weeks. orogastric tube

 Perform  To monitor the

Leopolds measurement and
maneuver attitude of the
fundus
NCP: BAG TECHNIQUE

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for infection After 30 minutes of After 30 minutes of
“hindi naming alam nursing interventions, the nursing interventions,
kung paano ang tamang family will be able to: the goal was met. The
paghuhugas ng kamay, family was able educate
pero okay lang di naman - Perform hand - Discuss to the - Improve their and perform proper hand
kami nagkakasakit” washing family that hand knowledge washing.
As verbalize by the washing is about proper
mother essential hand washing

Objective: - Discuss the - Implement ways

- Lack of possible risks of maintaining
inadequate for diseases and healthy and
knowledge complications infection and
about hand they can get disease free
hygiene when hand family
washing is not
- Inability to appropriately
recognize the performed
possible
infection and - Demonstrate - Perform proper
disease that they how hand hand washing
can get washing is and sterilization
properly technique
- Attitude and performed
philosophy in
life that hinders - Provide - Realize and
recognition adequate verbalize the
information of importance of
good benefits performing
proper hand
washing to
maintain
optimum level
of wellness.
NCP: PERINEAL CARE

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for infection Long term: Independent: Long term:
n/a related to presence of - After 2 days of - Change perineal - To prevent After 2 days of
surgical wounds as nursing pads frequently vaginal interventions the client
Objective: evidenced by MER interventions the contamination of was able to free from
- Presence of 2nd degree client will be able infection infections
perineal wounds to free from - Perform
due to infection. perineal care to - To promote Short term:
episiotomy Short term: the client cleanliness to the After 2 hours of nursing
secondary After 2 hours of perineal area interventions the client
degree interventions the client was able to:
will be able to: - Apply warm - To avoid edema - Verbalized health
- Not practicing - Verbalize health compress to the teaching
frequent teaching genital area
changing of - Demonstrate at - Demonstrated 3
pads least 3 ways on Collaborative: ways on
how to prevent - Sitz bath may - To aid healing of preventing
infection be ordered perineum infections
thorough
application of
moist heat
NCP: PERINEAL CARE

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION