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SOURCE; Delmar’s
Gelli’s and Maternal-
Kagan’s Infant
Current Nursing
Pediatric Care Plans
Therapy by 2nd edition by
Burg Karla Luxner
Ingelfinger p. p. 223
261
NURSING GOALS/EXPECTED NURSING
CUES/DATA RATIONALE RATIONALE EVALUATION
DIAGNOSIS OUTCOMES INTERVENTION
After 1 hour of
intervention, the
Subjective: Ineffective The preterm After 1 hour of goal is fully met.
thermoregulation newborn has nursing intervention, The neonate
N/A related to a great deal patient will maintain maintained a
Objective: immaturity and of difficulty normal body stable body
lack of attaining body temperature from temperature at
Gestational subcutaneous temperature 36.5-37.5 36 .7C
age of 34 and brown fat because she
weeks 2/7 INDEPENDENT: evidenced by:
has a
Current relatively 1. staff
weight: 2.0 1. Staff members Monitor the To
large surface will take steps neonate’s determine members
kgs kept
Neurological area per to maintain body the need
neonate’s temperature for neonate’s
status: kilogram of
body until discharge interventio body
LOC: body weight. temperature
temperature at n and the
Lethargic In addition, at normal
normal level. effectivene
Capillary refill because the ss of level.
Pt. will have a
time of 3 infant does therapy. neonate has
and warm, dry
seconds. not flex the warm, dry
skin
Integumentary body well but skin
Status: • Dry • Drying
pale legs,
remains in an
newborn quickly and
Moderate extended thoroughly and placing and
pallor position. quickly and placing on a
cool and dry Rapid cooling discard the wet warm, dry
skin from blanket. Place surface
Turgor: less evaporation is the infant under prevent heat
than 3 a pre warmed loss from
likely to
seconds occur. radiant warmer. evaporation.
neonate is
placed in the The preterm • Cold
isolation room infant has • Avoid surface and
Temperature: little placing infant instrument
35.5 C subcutaneous on cold surface increase
Mild shivering or using cold heat loss by
fat for
Baby is instrument in conduction
insulation and assessment.
placed in an
poor
extended
position muscular • To
Poor muscle development prevent
does not • Ambient excessive
tone
temperature of cooling.
Labs: allow the
the room where
Increased child to move the newborn is
Hemoglobin actively as kept should be
(198 g/l) the older monitored
increased infant does to • Helps
Hematocrit conserve
promote heat.
(0.58 g/l) • Mummify heat in the
The preterm
increased and use thick body
WBC (10.3 x infant also
blankets to
10 d/l) has limited 2. parents will cover the 2. parents
amount of express patient • The expressed
brown fat; understanding infant’s head understandin
• Teach the
of neonate’s provides a g of
special tissue mother about
thermoregulat large surface neonate’s
present in the infant’s
ory area for heat thermoregul
newborns to need for
disturbance loss atory
warmth and to
maintain body and disturbance
keep the
temperature. thermoregulati and
infant’s head
on thermoregul
covered
ation
Source: Careful
Maternal and teaching
Child Health Teach family allows
members family
Nursing, 4th
about: members
Ed. By -signs and to take an
Pillitteri, symptoms of active role
p.741 altered body in
temperature, maintaining
the
such as cool
neonate’s
extremities. health.
- factors in
home that Sources:
contribute to Ladewig et al.
neonatal heat Contemporar
loss and ways y Maternal-
to minimize Newborn
heat loss Nursing care
6th ed. P645
-importance of
Taylor Et.Al
contacting a
Nursing
health care
Diagnosis
provider when
Reference
problems
Manual 6th
related to temp
Ed. pp. 525-
regulation
526
NURSING GOALS/EXPECTED NURSING
CUES/DATA RATIONALE RATIONALE EVALUATION
DIAGNOSIS OUTCOMES INTERVENTION
• Newborns
• Inspect under phototherapy
perianal area lights have
after each increased loose
diaper change green acidic stools
for signs of which can be
breakdown irritating to the skin.
The diaper area
should be
thoroughly cleaned
after each soiled
diaper to prevent
skin breakdown.
• Avoid
using lotions or • Lotions and
ointments on ointments may
the newborn’s cause skin to burn
skin if applied to
exposed areas
during
phototherapy.
Source: Ladewig et al.
Contemporary Maternal-
Newborn Nursing care
6th ed. P759- 761