PALAWAN STATE UNIVERSITY COLLEGE OF NURSING AND HEALTH SCIENCES Puerto Princesa City

NURSING CARE PLAN

CUES

Nursing Diagnosis
Risk for hypothermia related to immaturity of newborn s temperature regulatory system as manifested by: y T-36.2 C y Newborn Exposure to cool environment y Not fully develop thermoregulati on y Conduction y Evaporation y Convection y radiation

Rationale
Newborn convection Radiation Conduction (The skin is not fully develop until 29 weeks of age)

Objective
After 8 hours of nursing interventions the SN will be able to:

Expected Outcome

Nursing Interventions

Rationale
.

Evaluation
After 8 hours of nsg.interventions the objective were completely met as evedinced by: K-Reported signs and symptoms seen and manifested by the baby such as: -T 36.2 C -Free from any complications.

y y

T-36.2 C Newborn Exposure to cool environment Not fully develop thermoregulati on

conduction (their warm body heat transfers to cooler objects that they come into direct contact with) evaporation from exposure of wet skin surfaces lost to

Evaporation

Conduction T-36 4C Risk for hypothermia

K-Identify the signs and symptoms of hypothermia such as: (a) Peripheral vasoconstriction -Acrocyanosis -Cool extremities -Decreased peripheral perfusion (b) CNS depression -Lethargy -Bradycardia -Apnea -Poor feeding (c) Increased

K-SN will identify and report atleast 10 signs and symptoms of hypothermia such as: (a) Peripheral vasoconstriction -cool extremities -decreased peripheral perfusion (b) CNS depression -Bradycardia -Apnea (c) Increased metabolism -Hypoxia

K-Discuss the signs and symptoms of hypothermia

K-To assess and recognize the signs and symptoms of hypothermia

the atmosphere convection (their body heats transfers to the air surrounding them) radiation (their warm body heat transfers to cooler objects around them)

related to to immaturity of newborn s temperature regulatory system

metabolism -Hypoglycemia -Hypoxia -Metabolic acidosis (d) Increase of pulmonary artery pressure -Distress -Tachypnea (e) Chronic signs -Weight loss, poor weight gain S-Demonstrate or show the Unang Yakap Program

-Metabolic acidosis (d) Increase of pulmonary artery pressure -Distress -Tachypnea (e) Chronic signs -Weight loss - poor weight gain

S-Perform the procedure immediately.

S-Provide -Immediate and thorough drying to stimulate breathing after delivery of the baby -Provision of appropriate thermal care through mother - newborn skin-to skin contact -maintaining a delivery room temperature of 25-28 degrees centigrade

S-To prevent further decreased in body temperature. -to restore normal temperature or organ function. -skin to skin contact is the best method to rewarming the baby until the temperature reaches the mormal range. -Balance among heat production,heat

S-Displayed temperature within normal range. T 37.2 C -Stabilized and maintained newborn s temperature.

- wrapping the newborn with clean, dry cloth -place knitcap on infant s head -place droplight or under radiant warmer

gain,and heat loss.

-Heat loss in newborn is greatest through head and by evaporation and convection. A-To promote wellness. -For the continuity of care. A-The procedure was done correctly and effectively.

A-Correctly maintain the positive participation in every procedure.

A-Maintain and update the Unang Yakap Program and other related factors about hypothermia and its ways of prevention.

A-Review and perform correctly the Unang Yakap Program and other related factors about hypothermia and its ways of prevention.

Name of Student: NEEZI E. NATIVIDAD,SN IV

References:PRENTICE HALL NANDA 8TH EDITION, BY: JUDITH M. WILKINSON,PhD,ARNP