NURSING CARE PLAN

Identified Problem: Decreased body temperature

Nursing Diagnosis: Risk for hypothermia related to immaturity of newborn’s temperature regulatory system

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives: Short term:
No data available 1. Establish rapport 1. To promote cooperation

Within 8 hours of providing
nursing care, patient’s body
temperature will rise from
36.3°C above
2. Provide therapeutic environment
3. Monitor patient’s  vital signs every hour
4. Regulate the environment temperature
or relocate the patient to a warmer
setting.
2. To provide comfort
3. To establish baseline data
4. To provide comfort to
patient
After 8 hours of providing nursing
interventions, patient’s body
temperature has started to rise.
STO is partially met

5. Keep patient dry and wrapped in blanket; 5. To prevent heat loss 

Objective: keep the head covered with a cap

V/S taken as follows: 6. Control the heat source according to the 6. Body temperature should
 T:36.3°C,  patient’s physical response be raised no more than a
 PR: 153 bpm,  few degrees per hour.
 SPO2 95% with 02  Vasodilation occurs as the
 RR: 60 cpm patient’s core temperature
Long term objectives: increases leading to a Long term:
 Cool skin decrease in BP.
Within 1 day of providing Hypotension, metabolic After 1 day of providing nursing
Anthropometric Measurements:  nursing care, the patient’s core acidosis, and dysrhythmias interventions, the patient’s core
 Height: 54cm body temperature will rise to are complications of body temperature is above
36.5°C but not higher than  rewarming. 36.5°C but not higher than 37.5°C
 HC:  34 cm
37.5°C 7. Explain procedures to patient’s SO or 7. To understand the LTO is met
 CC: 32 cm
mother interventions done to the
 AC: 30cm  patient and to avoid
 MAC:13 cm confusion
8. Encourage mother to hold baby for skin 8. Ways to stabilize the
to skin contact newborns body
temperature include placing
the infant directly on the
mother’s abdomen
Collaborative: Collaborative:
1. Restore/maintain core temperature 1. Client may require
within client’s normal range. May refer to interventions to treat
NDs Hypothermia hypothermia 

Patient’s Name / Room No. | 1

 NURSING CARE PLAN
Identified Problem: Risk for Infection

Nursing Diagnosis: Risk for Infection related to neonatal immune system

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Patient’s Name / Room No. | 2

Subjective: Short term objectives: Independent:
No data available
1. Establish rapport
Within an hour, patient will
demonstrate a 2. Provide therapeutic environment
meticulous hand
washing technique. 3. Monitor for signs and symptoms of
infection
4. Ensure that any articles used are
properly disinfected or sterilized before
Objective: use
-Pt’s Mother did not have any
prenatal check-ups. 5. Wash hands or perform hand hygiene
-Skin is cracking pale with rare before having contact with the patient.
veins Also impart these duties to the patient
-vital signs taken as follows: and their significant others. Know the
T:36.3C instances when to perform hand hygiene
PR: 153 bpm or “5 moments for hand hygiene”:
RR: 60 cpm
SPO2 95% with 02  Before touching a patient
Long term objectives:  Before clean or aseptic
procedure (wound dressing,
Patient will remain free of starting an IV, etc)
infection  After body fluid exposure
 After touching a patient
 After touching the patiend’s
surroundings
6. Educate clients and SO about
appropriate methods for cleaning,
disinfecting, and sterilizing items
7. Perform measures to break the chain of
infection and prevent infection
Short term:
1. To promote cooperation
After an hour, patient has
2. To provide comfort demonstrated a meticulous hand
washing technique. STO is met
3. Signs and symptoms of
infection vary according to
the body area involved.
4. This reduces or eliminates
germs.
5. Friction and running water
effectively remove
microorganisms from
hands. Washing between
procedures reduces the
risk of transmitting
pathogens from one area of
the body to another. Wash
hands with antiseptic soap Long term:
and water for at least 15
seconds followed by Patient remains free of infection,
alcohol-based hand rub. If as evidenced by normal vital
hands were not in contact signs and absence of signs and
with anyone or anything in symptoms of infection. LTO is met
the room, use an alcohol-
based hand rub and rub
until dry. Plain soap is good
at reducing bacterial counts
but antimicrobial soap is
better, and alcohol-based
hand rubs are the best.
6. Knowledge of ways to
reduce or eliminate germs
reduces the likelihood of
transmission.
7. The following methods help
break the chain of infection,
and prevent conditions that
may be suitable for
Patient’s Name / Room No. | 3
 microbial growth:
1. Change dressing and
bandages that are soiled or
wet.
2. Assist clients in carrying
out appropriate skin and
oral hygiene.
3. Dispose of soiled linens
properly.
4. Ensure all fluid
containers are covered or
capped.
5. Avoid talking, coughing,
or sneezing over open
wounds or sterile fields.
6. Wear gloves when
handling patient secretions.
7. Instruct clients to
perform hand hygiene
when handling food or
eating.

8. Limit visitors 8. Restricting visitation

reduces the transmission of
pathogens.

9. Provide surgical masks to visitors who 9. Educating visitors on the

are coughing and provide rationale to importance of preventing
enforce usage. Instruct visitors to cover droplet transmission from
mouth and nose (by using the elbows to themselves to others
cover) during coughing or sneezing; use reduces the risk of
of tissues to contain respiratory infection.
secretions with immediate disposal to a
no-touch receptacle; perform hand
hygiene afterward.

10. Place the patient in protective isolation if 10. Protective isolation is set
the patient is at high risk of infection. when the WBC indicates
neutropenia.

11. Teach the importance of avoiding
contact with individuals who have
infections or colds. Teach the importance
of physical distancing.
11. Other people can spread
infections or colds to a
susceptible patient (e.g.,
immunocompromised)
through direct contact,

Patient’s Name / Room No. | 4


Dependent:
12. Crede's prophylaxis (Tetracyline 1%,
Erythromycin 0.5%) ointment OU
13. Vitamin K (Phytonadione) 0.1ml (10mg)
IM at vastus lateralis, right
14. Hepatitis B Vaccine 0.5 ml IM @ vastus
lateralis, left
15. BCG Vaccine (dose: 0.05 ml) ID @ R
deltoid
Identified Problem: Ineffective Infant Breastfeeding
Nursing Diagnosis: Ineffective infant breastfeeding related to poor sucking reflex of the patient
CUES OBJECTIVES INTERVENTIONS
contaminated objects, or
through air currents.
12. represented a tremendous
step forward in the
prevention of inflammatory
eye disease in newborns in
the late 19th century.
13. Low levels of vitamin K can
lead to
dangerous bleeding in
newborns and infants. The
vitamin K given at birth
provides protection
against bleeding that could
occur because of low levels
of this essential vitamin.
14.  They will be protected as
early as possible from any
exposure to the hepatitis
B virus
15. Helps your child’s immune
system fight the germs that
cause TB and helps stop
them from getting serious
TB disease.
RATIONALE EVALUATION
Patient’s Name / Room No. | 5
Subjective: Short term objectives: Independent Short term:

“Gasakit akoang tahi kung Within 8 hours of providing
mangihi ko”  nursing care, the patient
will able:
“Dili ko kamao mutambal sa -To improve his sucking reflex
akoang samad” as verbalized during breastfeeding.
by the patient.  
-To improve the mother and
infant’s breastfeeding
practices and techniques.
. health benefits to both mother and her
1. Established rapport 1. To promote cooperation After 8 hours of providing
nursing care, the patient was
2. Provide privacy 2. Breastfeeding needs to take able to improve his suckling
place in a setting where the reflex and intake breast milk
mother of the infant is able to properly due to improved
freely feed her baby. breastfeeding practices and
techniques.
3. Explain to the mother the process and 3. It will let the mother to have a
importance of breastfeeding. Include the better understanding on the
benefits of breastfeeding. It will
child motivate them to achieve their
goal.

4. It will let the mother and baby to

Objective: 4. Explain the correct positioning of the have a successful breastfeeding Long term:
mother and infant during breastfeeding through correct positioning. This
 Inability of the patient Long term objectives: by demonstrating the proper technique. will prevent disruption of the After 3 days of providing
to suck/swallow process. nursing care, the patient was
effectively is noted Within 7 days of providing able to intake adequate
nursing care, the patient will 5. Proper positioning of the infant breast milk and gain proper
 Poor sucking with his be able to manifests signs of 5. Check the infant’s ability to grasp the during breastfeeding aids in the nutrition as evidenced by
mom’s breast cries adequate improvement in his areola of the breast with his lips, tongue success of the infant to patient’s steady weight gain,
immediately and breast milk intake and gain and jaw. breastfeed form his mother. pass more urine several
looked uncomfortable proper nutrition. times a day, color of his stool
with the position. 6. To aid the infant in maintaining a is converted to dark yellow,
successful breastfeeding. sleeping peacefully for a
6. Check the infant’s ability to suck breast longer duration
milk 7. This will prevent disruption of the
breastfeeding process and
promote successful infant
Vital Signs: 7. Promote relaxation and comfort during feeding.
 T: 36.3C breastfeeding process. Provide a calm,
 PR: 153bpm quiet and non-stimulating environment
 RR: 60cpm while feeding.
 SPO2 95% with O2
8. Reinforces that feeding time is
pleasurable and enhances
8. Recommend for infant sucking on a digestion.
regular basis

Patient’s Name / Room No. | 6

Collaborative
1. Refer the mother and new born to the
attending physician if there is an unusual
symptom during breastfeeding.
9. It will prevent interference with
proper feeding pattern and so as
to maintain infant’s proper
nutrition.
Patient’s Name / Room No. | 7