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Karisa M. Young April 28, 2005 Nursing 374L 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 Dx: Ineffective thermoregulation related to immature temperature control and decreased subcutaneous body fat.
Plan/Goal Plan: to monitor newborn closely to maintain temperature and prevent hyperthermia and cold stress Goals: Long-term: Newborn will be able to sustain adequate/normal self thermoregulation. Short-term: Provide assistance and support to 2. Mother will verbalize possible methods of heat loss & demonstrate understanding of conduction, convection, radiation, & evaporation 2. Provide heat/warm the newborn using incubators, radiant warmer, swaddling, and skin-to-skin contact. 3. Maintain thermal neutral Outcome Criteria 1.
Infant’s body temperature will remain within normal axillary range, 36. 5-37 degrees Celsius (Glass, 1999, p. 188). Interventions 1. Monitor axillary temperature at least every 8 hours; more frequently for infants at high risk. Rationale Evaluation 1. Regular 1. Newborn self temperature maintains monitoring will adequate body identify temperature for adequate or 24 hours prior inadequate to discharge. thermoregulati on (Glass, 2. Mother 1999, p. 188). demonstrates Axillary effective temperature is maintenance of good indicator neutral thermal of newborn’s environment surface within 24 hours. emperature (Glass, 1999, 3. Mother p. 188). verbalizes methods of 2. To warm the possible heat newborn and loss within 12 maintain adequate/normal temperature within 12 hours. 3. Mother will demonstrate maintenance of a neutral thermal environment within 24 hours. 4. Mother will demonstrate proper skin-toskin warming technique prior t discharge. environment and avoid situations that might predispose the infant to heat loss, such as cool air, drafts, bathing, and cold bedding. adequately maintain accepted thermal range (Wong, 2003, p. 371). 3.
To maintain stable body temperature of the newborn and decrease the possibility of heat loss through conduction, convection, radiation, & evaporation (Wong, 2003, p. 371). hours. 4. Mother demonstrates proper skin-to skin warming technique prior to discharge. 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.