ST. ANTHONY COLLEGE CALAPAN CITY, INC.

Bayanan I, Calapan City

NURSING CARE PLAN

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
OBJECTIVE: Ineffective After 30 - Obtained vital - To - After nursing
Temperature thermo- minutes of signs determine intervention, the
34.5°C regulation: as nursing especially the the vital sign baby’s
manifested by intervention the temperature are with in temperature is
SUBJECTIVE: cold to touch of baby’s body normal within normal
Shivering of both the upper and temperature will range range was
upper and lower lower be maintained maintained to
extremities. extremities. to normal °
36.7 . C Goal
temperature met.
from 34.7° C to
- Provide an - To reduce
36.5° C
immediate heat loss
drying of the from
patient after evaporation,
birth. dry the baby
right after
birth with a
dry towel or
cloth.

- Skin-to-skin
- Skin-to-skin
contact with
contact for 2
the mother and
hours as
keep covered
DOH
with blanket.
directive
helps to

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 ST. ANTHONY COLLEGE CALAPAN CITY, INC.

Bayanan I, Calapan City

maintain
stabilization
of
temperature.
- Provide a cap
on the baby’s
head and - Putting a
cover the body cap on the
with a second head
towel. prevents
heat loss
from
convection.

- Placing a clean
sheet or diaper - To avoid
before direct
weighing the contact to
baby. weighing
scale and to
prevent heat
loss through
conduction.

- Anthropometric
measurement
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 ST. ANTHONY COLLEGE CALAPAN CITY, INC.

Bayanan I, Calapan City

will be taken - So other

after 2 hours of parts of the
the skin-to-skin body will not
contact and to be exposed
expose only to cold
the parts to be environment.
measured.

- Dressed the
baby after the
routine new - To make
born care and sure that the
place under baby will be
drop light. warm and to
provide
effective
thermal
control
reducing the
risk of
hypothermia.

- Exposed only
the right and
left vastus - To prevent
lateralis when gonococcal
administering infection and other

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 ST. ANTHONY COLLEGE CALAPAN CITY, INC.

Bayanan I, Calapan City

of 0.1ml of parts of the body

Vitamin K and will not be exposed
0.5ml of HEPA to cold
B vaccine and environment.
erythromycin
ointment.

- Dressed the
baby after the
routine new
born care and
exposed to
drop light and
to transfer to
the mother
once if there is
a good
sucking.

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