NURSING CARE PLAN NO.

1: NEWBORN

NURSING NURSING OUTCOME

DATE ASSESSMENT NURSING GOAL RATIONALE EVALUATION
DIAGNOSIS INTERVENTION CRITERIA

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.

 Clear the airway;

nasopharyngeal suction  Helps eliminate
 slowly, as needed. accumulation of fluid,
Monitor the apical pulse facilitates breathing
during suctioning. efforts, and help prevent
aspiration. Inhalation of
oropharynx cause vagal
stimulation that lead to
 Dry the baby with a bradycardia.
warm blanket, place
stockings head cover, and  Lowering effects of
place it in the arms of cold stress (ie., An
parents. increase in oxygen
demand) and is associated
with hypoxia, which can
further depress respiration
effort and lead to acidosis
when the baby force with
the end product of
 Put the baby in a anaerobic metabolism of
modified Trendelenburg lactic acid.
position at an angle of 10
degrees.  Facilitate the drainage
of mucus from the
nasopharynx and trachea
with gravity.

NURSING CARE PLAN NO. 2: NEWBORN

 NURSING NURSING OUTCOME
DATE ASSESSMENT NURSING GOAL RATIONALE EVALUATION
DIAGNOSIS INTERVENTION CRITERIA

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).

 Place the newborn  Prevent heat loss

in warm environments or through conduction, in
at arm's parents. Warm which heat is removed from
objects that contact the the newborn to the object or
baby (ie., Scales, surface that is cooler than
stethoscopes, examination the baby. Being held tightly
table and hands). near the body of parents of
newborns and skin contact
with the skin reduce heat
loss in newborns.

 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).

 Assess the  Body temperature

neonate's core should be maintained closer
temperature, skin to 36,5˚C (97,6˚F). Core
temperature secar temperature (rectal) usually
continuous monitoring 0,5˚C (0,9˚F) higher than
with skin testing tool skin temperature, but the
 appropriately. continuous displacement of
the core to the skin occurs
so that the difference
between the core and skin
temperature is greater, the
faster removal is becoming
increasingly rapid
temperature cool.

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