Professional Documents
Culture Documents
SOURCE; Delmar’s
Gelli’s and Maternal-
Kagan’s Infant
Current Nursing
Pediatric Care Plans
Therapy by 2nd edition by
Burg Karla Luxner
Ingelfinger p. p. 223
261
NURSING GOALS/EXPECTED NURSING
CUES/DATA RATIONALE RATIONALE EVALUATION
DIAGNOSIS OUTCOMES INTERVENTION
After 1 hour of
intervention, the
Subjective: Ineffective The preterm After 1 hour of goal is fully met.
thermoregulation newborn has nursing intervention, The neonate
N/A related to a great deal patient will maintain maintained a
Objective: immaturity and of difficulty normal body stable body
lack of attaining body temperature from temperature at
Gestational subcutaneous temperature 36.5-37.5 36 .7C
age of 34 and brown fat because she
weeks 2/7 INDEPENDENT: evidenced by:
has a
Current relatively 1. staff
weight: 2.0 1. Staff members Monitor the To
large surface will take steps neonate’s determine members
kgs kept
Neurological area per to maintain body the need
neonate’s temperature for neonate’s
status: kilogram of
body until discharge interventio body
LOC: body weight. temperature
temperature at n and the
Lethargic In addition, at normal
normal level. effectivene
Capillary refill because the ss of level.
Pt. will have a
time of 3 infant does therapy. neonate has
and warm, dry
seconds. not flex the warm, dry
skin
Integumentary body well but skin
Status: • Dry newborn • Drying
pale legs,
remains in an
thoroughly quickly
Moderate extended and quickly and
pallor position. and discard placing
cool and dry Rapid cooling the wet and
skin from blanket. placing on
Turgor: less evaporation is Place the a warm,
than 3 infant under a dry
likely to
seconds occur. pre warmed surface
neonate is radiant prevent
placed in the The preterm warmer. heat loss
isolation room infant has from
Temperature: little evaporatio
35.5 C subcutaneous • Avoid placing n.
Mild shivering infant on cold
fat for
Baby is surface or • Cold
insulation and using cold
placed in an surface
poor instrument in and
extended
position muscular assessment. instrument
Poor muscle development increase
tone does not heat loss
Labs: allow the by
• Ambient conduction
Increased child to move
temperature
Hemoglobin actively as of the room
(198 g/l) the older where the • To prevent
increased infant does to newborn is excessive
Hematocrit kept should
promote heat. cooling.
(0.58 g/l) be monitored
The preterm
increased
WBC (10.3 x infant also
10 d/l) has limited 2. parents will 2. parents
• Mummify and
amount of express expressed
use thick • Helps
brown fat; understanding understandin
blankets to conserve
of neonate’s g of
special tissue cover the heat in the
thermoregulat neonate’s
present in patient body
ory thermoregul
newborns to disturbance • Teach the atory
maintain body and mother about disturbance
the infant’s • The
temperature. thermoregulati and
need for infant’s
on thermoregul
warmth and head
ation
to keep the provides a
infant’s head large
Source: covered surface
Maternal and area for
Child Health heat loss
Nursing, 4th
Ed. By Teach family
Pillitteri, members
p.741 about:
-signs and
symptoms of Careful
altered body teaching
allows
temperature, family
such as cool members
extremities. to take an
active role
- factors in in
home that maintaining
contribute to the
neonatal heat neonate’s
loss and ways health.
to minimize
heat loss Sources:
Ladewig et al.
-importance of
Contemporar
contacting a
y Maternal-
health care
Newborn
provider when
Nursing care
problems
6th ed. P645
related to temp
Taylor Et.Al
regulation Nursing
Diagnosis
Reference
Manual 6th
Ed. pp. 525-
526
NURSING GOALS/EXPECTED NURSING
CUES/DATA RATIONALE RATIONALE EVALUATION
DIAGNOSIS OUTCOMES INTERVENTION