ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Objective: Ineffective After 2 hours of nursing intervention: • Monitor axillary temperature After 2 hours of nursing
Temperature of thermoregulation The newborn will maintain temperature at least every 1 hour intervention:
35.8 related to immature and prevent hyperthermia and cold • Provide heat/warm of The newborn maintained
temperature control stress. newborn using swaddling, temperature and prevent
and decreased Goals: droplight and skin-to-skin hyperthermia and cold
subcutaneous body Long-term: contact. stress.
fat Newborn will be able to sustain • Maintain thermal neutral Goals:
adequate/normal self thermoregulation. environment and avoid Long-term:
Short-term: situation that might Newborn was able to
Provide assistance and support to predispose the infant to heat sustain adequate/normal
maintain adequate normal temperature loss, such as cool air, drafts, self thermoregulation.
bathing and cold beddings. Short-term:
Provides assistance and
support to maintain
adequate normal
temperature

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Objective: Disorganized infant After 2 hours of nursing • monitor body temperature every 1 After 2 hours of nursing
• Crying behavior related to cold intervention: to 3 hours intervention:
• unable to feed room temperature The newborn will have a • monitor and record neurologic The newborn had a good
• cold room good behavior status every 1 to 4 hours behavior
temperature • Maintain thermal neutral
environment and avoid situation
that might predispose the infant to
heat loss, such as cool air, drafts,
bathing and cold beddings.
• Provide heat/warm of newborn
using swaddling, droplight and
skin-to-skin contact.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Objective: Readiness for After 8 hours of nursing intervention: • Determine After 8 hours of nursing
Presence of enhance nutrition The newborn will be able to be ready for patterns of intervention:
sucking reflex related to the the enhancement of his nutrition hunger and The newborn was able to be ready
Presence of attitude towards Goals: satiety for the enhancement of his
rooting reflex the feeding bottle Long-term: • Obtain safe nutrition
Newborn will be able to enhance his preparation and Goals:
nutrition. storage of food Long-term:
Short-term: Newborn was able to enhance his
Provide assistance and support to nutrition.
maintain to enhance his nutrition Short-term:
Provides assistance and support
to maintain to enhance his
nutrition

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Objective: Ineffective breathing After 1 hour of nursing • obtain vital signs every 1 hour After 1 hour of nursing
• RR: 67 pattern related to intervention: • suction ororpharynx and intervention:
• Small for adjustment to The newborn will be to nasopharynx as needed The newborn was be to
gestational age extrauterine existence adjust to his extrauterine • provide oxygen as needed adjust to his extrauterine
• Altered chest life • .maintain neutral environment life
excursion Goals: Goals:
• Accessory Long-term: Long-term:
muscle use Newborn will be maintain Newborn was be maintain
• Dyspnea his adjustment to his adjustment to
extrauterine life extrauterine life
• Nasal flaring
Short-term: Short-term:
• retractions Provide assistance and Provides assistance and
support to maintain support to maintain
normal respiratory status normal respiratory status