Nursing Care Plan No.1: Newborn
Nursing Care Plan No.1: Newborn
Nursing Care Plan No.1: Newborn
1: NEWBORN
06/12/20 SUBJECTIVE Risk for After 1 hour of nurse- INDEPENDENT Demonstrate After 1 hour of nurse-client
CUES: impaired gas client interaction, the improved interaction, the client was
exchange client will be able to: Measure the Apgar Help determine the ventilation and able to:
N/A related to score in the first minute need for immediate adequate
antepartum Client will be free and five minutes after intervention (ie., Suction, oxygenation of Client was free from signs
stress from signs of birth. oxygen). Total score from tissues by of respiratory distress.
respiratory distress. 0 to 3 showed severe ABGs within
OBJECTIVE asphyxia or possibility to client’s normal Client’s skin returned to its
CUES: Client will return to control neurological limits and normal color.
Abnormal its normal skin color dysfunction and / or absence of
breathing from being pale. chemically with breathing. symptoms of
Scores 4 to 6 aggravate the respiratory
Abnormal skin difficulty adapting to distress
color extrauterine life. Score 7 to Participate in
10 indicates no trouble treatment
adapting to extrauterine regimen within
life. level of
Note the prenatal ability/situation
complications that affect This complication can .
the status of the placenta lead to chronic hypoxia
and / or fetal (ie., Heart or and acidosis, increasing
kidney disorders, the risk of damage to the
hypertension due to central nervous system and
pregnancy, or diabetes). require repair after birth.
06/12/20 SUBJECTIVE Risk for altered After 1 hour of nurse- INDEPENDENT Maintain After 1 hour of nurse-client
CUES: body client interaction, the body interaction, the client was
temperature client will be able to: Note the presence To prevent oxygen temperature able to:
N/A related to of fetal distress or deprivation. within
inability to Client will be free of hypoxia. normal Client was free of signs of
chills signs of respiratory range. respiratory distress and cold
distress and cold Demonstrat stress.
Dry the head and Reduce heat loss
OBJECTIVE stress. e behaviors
the body of a newborn due to evaporation and
CUES: for
baby, put the stockings conduction, humidity monitoring
headgear; and wrap in a protects the baby from the
Body and
warm blanket. air flow or air conditioner,
temperature maintaining
below normal and limit the stress of appropriate
range displacement of the uterus body
warm environment to a cold temperature.
Cool, pale skin environment (possibly 5 F
[19 ° C] lower than the
Increased heart temperature of
rate intrauterine) , (Note: Due to
the relatively large area of a
newborn baby's head in
relation to the body, the
baby can experience
dramatic heat loss of
moisture, the head is not
closed).
A decrease in
Note the ambient ambient temperature 2 ° C
temperature. Eliminate air (3.6 F) sufficient to indicate
flow and minimize the use neonatal oxygen
of air conditioning; warm consumption. Heat loss
up when given oxygen through convection occurs
through a mask. when the baby loses heat to
the cooler air flow. Lost via
radiation occurs when heat
is removed from the
newborn to the object or
surface that is not directly
related to the newborn (ie.,
The walls of the incubator).
References:
Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2008). Nurse’s Pocket Guide. (11th ed., pp. 120-123, & 337-341).
Newborn Priority Nursing Diagnosis and Intervention. (2015). Retrieved from: https://nurses-nanda.blogspot.com/2015/09/newborn-priority-nursing-diagnosis-and.html