Karisa M.

Young Nursing 374L

April 28, 2005 Nursing Care Plan

Twin ‘B’ was born on Monday February 14, 2005 at 35 weeks gestation. The mother was scheduled for a cesarean section at 38 weeks
gestation, but presented in the hospital early with signs of labor. A cesarean delivery was performed. Twin ‘B’ APGAR scores at 1
minute and 5 minutes were 9 and the newborn weighted 4lbs 3 oz. Upon completion of the assessment, the newborn’s temperature
decreased to 96.1 degree Celsius (axillary).

Diagnosis Plan/Goal Outcome Criteria Interventions Rationale Evaluation

Dx: Ineffective Plan: to monitor 1. Infant’s body 1. Monitor 1. Regular 1. Newborn self
thermoregulation newborn closely to temperature will axillary temperature maintains
related to immature maintain remain within temperature at monitoring will adequate body
temperature control temperature and normal axillary least every 8 identify temperature for
and decreased prevent range, 36.5-37 hours; more adequate or 24 hours prior
subcutaneous body hyperthermia and degrees Celsius frequently for inadequate to discharge.
fat. cold stress (Glass, 1999, p. infants at high thermoregulati
188). risk. on (Glass, 2. Mother
Goals: 1999, p.188). demonstrates
2. Mother will 2. Provide Axillary effective
Long-term: verbalize heat/warm the temperature is maintenance of
Newborn will be possible newborn using good indicator neutral thermal
able to sustain methods of heat incubators, of newborn’s environment
adequate/normal loss & radiant warmer, surface within 24 hours.
self demonstrate swaddling, and temperature
thermoregulation. understanding skin-to-skin (Glass, 1999, 3. Mother
of conduction, contact. p. 188). verbalizes
Short-term: convection, methods of
Provide assistance radiation, & 3. Maintain 2. To warm the possible heat
and support to evaporation thermal neutral newborn and loss within 12
 maintain within 12 hours. environment adequately hours.
adequate/normal and avoid maintain
temperature 3. Mother will situations that accepted 4. Mother
demonstrate might thermal range demonstrates
maintenance of predispose the (Wong, 2003, proper skin-to
a neutral infant to heat p. 371). skin warming
thermal loss, such as technique prior
environment cool air, drafts, 3. To maintain to discharge.
within 24 hours. bathing, and stable body
cold bedding. temperature of
4. Mother will the newborn
demonstrate and decrease
proper skin-to- the possibility
skin warming of heat loss
technique prior through
t discharge. conduction,
convection,
radiation, &
evaporation
(Wong, 2003,
p. 371).

References:

Davis, F.A. (2004). Nurse’s Pocket Guide: Diagnoses, Interventions, and Rationales. (9th ed.). Philadelphia: F.A. Davis Company.

Glass, S. M. (1999). Assessment and Care of the Well Newborn. Philadelphia: W.B. Saunders Company.
Hockenberry, M. (2003). Wong’s Nursing Care of Infants and Children. (7th ed.). St Louis: Mosby.