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lan NURSING CARE PLAN| ASSESSTMENT| BACKGROUND KNOWLEDGE| PLANNING| INTERVENTION| RATIONALE| EVALUATION| Subjective:n/aObjective: * Preterm birth (36 weeks) * Weight: 1. 75kgs. * Cool and dry skin. * Temperature: 33. 6 degrees Celsius. * Poor muscle tone. * Placed under two droplights. Nursing Diagnosis: Ineffective thermoregulation related to immaturity. | Vaginal birthPretermPoor muscle developmenthypothermia| After 1 hour of nursing intervention, patient will maintain ormal body temperature from 36. 5-37. 5| (1)Monitor the neonate’s Body temperature until discharge(2) Dry newborn thoroughly and quickly and discard the wet blanket. Place the infant under pre warm radiant warmer(3) Avoid placing infant on cold surface or using cold instrument in assessment. (4)ambient temperature of the room where the newborn is kept should be monitored(5) Teach the mother about the infant’s need for warmth and to kept the infants head covered. 6) Teach family members about signs and symptoms of altered body temperature, such as cool extremities. (7) importance of contacting a health care provider when problems related to temp. | (1)To determine the need for intervention n and the effectiveness of therapy. (2) Drying quickly and placing and placing on a warm, dry surface prevent heat loss. (3) Cold surface and instrument increase heat lossby conduction (4)to prevent excessive cooling. 5) the infants head provides a large surface area for heat loss. (6-7) Careful teaching allows family members to take an active role in maintaining the neonate’s health. | After 1 hour of intervention, the goal is fully met. The neonate maintained a stable body temperature at 36. 7 C. | CASE: Baby girl Mortel REMARKS: C. I. ‘s Sig. :AREA| AREA: DATE: September 17, 2010|