NURSING

NURSINGCARE
CARE
PLAN
PLAN
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Objectives; Ineffective Within 90 mins. of  Monitor axillary  Regular After 30 mins. of

thermoregulation r/t mummifying the temperature at temperature mummifying the
 acrocyanosis decrease infant, maintaining least every 3 monitoring will infant, maintaining
 Capillary refill subcutaneous body thermal neutral hours or as identify adequate thermal neutral
time of 3 necessary. or inadequate
fat 20 newborn environment such environment such
seconds. thermoregulation.
hypothermia as turning off the Axillary as turning off the
 Apnea
 cool pale air-conditioned, temperature is air-conditioned,
extremities monitoring the good indicator of monitoring the
 dry skin axillary newborn’s axillary temperature
 Temperature: temperature as surface as necessary the
35.5 C necessary body will temperature body minimize heat
 Dyspnea minimize heat loss,  Provide loss, warm, and dry
 RR:68 bpm  To warm the
warm, and dry skin heat/warm the newborn and skin
newborn using adequately
incubators, maintain
radiant warmer, accepted thermal
and skin-to-skin range
contact.

 To maintain
 Maintain thermal stable body
neutral temperature of
environment and the newborn and
avoid situations decrease the
that might possibility of heat
predispose the loss through
 infant to heat conduction,
loss, such as convection,
cool air, drafts, radiation, &
bathing, and cold evaporation
bedding.

 Dry newborn  Drying quickly

thoroughly and and placing and
quickly and placing on a
discard the wet warm, dry
blanket. Place surface prevent
the infant under heat loss from
a pre warmed evaporation.
radiant warmer.

 Cold surface and

 Avoid placing instrument
infant on cold increase heat
surface or using loss by
cold instrument conduction
in assessment.

 Ambient
temperature of  To prevent
the room where excessive
the newborn is cooling.
kept should be
monitored

 Mummify and
use thick  Helps conserve
blankets to cover heat in the body
the patient
  The infant’s head
provides a large
 Teach the surface area for
mother about the heat loss
infant’s need for
warmth and to
keep the infant’s
head covered

Careful teaching
allows family
 Teach family members to take an
members about: active role in
maintaining the
neonate’s health
 -signs and
symptoms of
altered body
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 temp
regulation