CUES/ DATA NURSING RATIONALE GOALS/ NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTIONS

Subjective: Ineffective A premature After 30 minutes INDEPENDENT: After 30 minutes
breathing lung is of nursing (1) assess RR (1) of nursing
n/a pattern structurally interventions, the and pattern assessment interventions,
related to underdevelope infant will provides goal is partially
Objective: immature d for postnatal experience an information met, the infant
neurologic life. To add, effective about experienced an
- Preterm birth and delayed the premature breathing pattern neonate’s effective
(34 wks and pulmonary delivery and as manifested by ability to breathing pattern
2days) development the inadequate initiate and as manifested by
- With Oxygen pulmonary - Infant’s RR sustain an
hood surfactant. A is between effective - Infant’s
regulated at deficiency in 40 and 60 breathing RR was
10 liters per surfactant, - Infant will pattern between
minute which functions experience (2) provide (2) 40 and 60
- RR:58 cycles/  to decrease no apnea respiratory assistance - Infant
min the surface assistance as helps the experienc
- Episodes of tension within needed (oxygen newborn by ed less
apnea (6- 10 the alveoli. hood) clearing the episodes
secs) Without airway and of apnea
- O2 saturation surfactant, the promoting
of 91% infant oxygenation
experiences (3) position infant (3) lying on
diffuse on side with a the side
atelectasis, rolled blanket position
decreased behind his back facilitate
pulmonary breathing
compliance, (4) provide tactile (4)
ventilation stimulation during stimulation
perfusion periods of apnea of the
mismatching, sympathetic
and significant nervous
increase in the system
work of increases
breathing. respiration

SOURCE; Delmar’s
Gelli’s and Maternal-
Kagan’s Infant
Current Nursing
Pediatric Care Plans
Therapy by 2nd edition
Burg by Karla
Ingelfinger p. Luxner p.
261 223
 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,
N/A The neonate
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 evidenced
age of 34 and brown fat because she
weeks 2/7 INDEPENDENT: by:
has a
 Current
weight: 2.0 relatively 1. Staff members  Monitor the  To 1. staff
large surface will take steps neonate’s determine members
kgs
area per to maintain body the need kept
 Neurological
status: neonate’s temperature for neonate’s
kilogram of
body until discharge intervention body
 LOC: body weight.
temperature at and the temperature
Lethargic In addition,
normal level. effectivene at normal
 Capillary refill
because the Pt. will have a ss of level.
time of 3
infant does and warm, dry therapy. neonate has
seconds.
Integumentary not flex the skin warm, dry


Status: body well but skin

Dry newborn Drying

 pale legs, remains in an thoroughly and quickly and
Moderate extended quickly and placing and
pallor position. discard the wet placing on a
 cool and dry
Rapid cooling blanket. Place warm, dry
skin
from the infant under surface
 Turgor: less
evaporation is a pre warmed prevent heat
than 3
radiant warmer. loss from
seconds likely to
 neonate is occur. evaporation.
placed in the
isolation room The preterm Avoid placing
 Cold surface


 Temperature: infant has infant on cold and

35.5 C little surface or using instrument
 Mild shivering subcutaneous cold instrument increase
 Baby is in assessment. heat loss by
fat for
placed in an conduction
extended insulation and
position poor
 Poor muscle muscular Ambient
 To prevent


tone development temperature of excessive

 Labs: does not the room where cooling.
 Increased the newborn is
allow the
Hemoglobin kept should be
child to move monitored
(198 g/l)
 increased actively as
Hematocrit the older Helps


(0.58 g/l) infant does to Mummify and

 conserve
 increased promote heat. use thick heat in the
WBC (10.3 x blankets to body
The preterm
10 d/l) cover the
infant also patient
has limited 2. parents will Teach the
 The infant’s

2. parents
amount of express mother about head expressed
brown fat; understanding the infant’s provides a understandin
of neonate’s need for large surface g of
special tissue
thermoregulat warmth and to area for heat neonate’s
present in ory thermoregula
keep the loss
newborns to disturbance tory
infant’s head
maintain body and covered disturbance
temperature. thermoregulati and
on thermoregula
tion
Source:  Teach family  Careful
Maternal and members teaching
Child Health about: allows
-signs and family
Nursing, 4th
symptoms of members
Ed. By to take an
altered body
Pillitteri, active role
temperature,
p.741 in
such as cool maintaining
extremities. the
neonate’s
- factors in health.
home that
contribute to
neonatal heat Sources:
loss and ways Ladewig et al.
to minimize Contemporary
heat loss Maternal-
Newborn
-importance of Nursing care
contacting a 6th ed. P645
health care Taylor Et.Al
provider when Nursing
problems Diagnosis
related to temp Reference
regulation Manual 6th
Ed. pp. 525-
526
ordered growth of bacteria
and destruction of
bacteria.
Delmar’s
Maternal- Infant
Nursing Care
Plans 2nd edition
by Karla Luxner p.
237
 Cues Nursing Rationale Goals and Interventions Rationale Evaluation
Diagnosis Objectives

After 8 hours of After 8

nursing hours of
Objective: Risk for The newborn
intervention nursing
Impaired skin lies in one
 Patient is intervention,
integrity related position for a
on goal is fully
to exposure to long period of
photothera 1. Patient’s skin met.
py for 4 high intensity time that may
will remain Patient’s
days light result in skin
intact skin
 Consumes secondary to breakdown.
remained
5 diapers phototherapy Due to lack of
intact as
per day adipose INDEPENDENT:
Slightly evidenced

tissue, the by:
 jaundice in
pressure
color  No signs of
exerted by  No signs
 Dry skin skin  Change Patient position

bony of skin
 Patient in breakdown position every changes will allow
prominences breakdow
supine 2 hours exposure of the
on the skin is n
position phototherapy lights
 Has no greater thus to all areas of the
clothes on increases the body that are
during risk of skin uncovered.
photothera Pressure areas
breakdown.
py, only may develop if
mittens, newborn lies in one
socks, and position for an
diapers Source: extended period of
 Has eye time.
Ladewig et al.
cover Contemporary
during Maternal-
phototherapy Patient may
Newborn 

Nursing care develop a

 Monitor skin maculopapular rash
6th ed. P763 for rashes and which is transient
bronzing every side effect of
8 hours. phototherapy

 Inspect Newborns under

perianal area phototherapy lights
after each have increased
diaper change loose green acidic
for signs of stools which can be
breakdown irritating to the skin.
The diaper area
should be
thoroughly cleaned
after each soiled
diaper to prevent
skin breakdown.

 Avoid using
lotions or  Lotions and
ointments on ointments may
the newborn’s cause skin to burn
skin if applied to
exposed areas
during
phototherapy.
Source: Ladewig et al.
Contemporary Maternal-
Newborn Nursing care
Dx: Ineffective Plan: to monitor 1. Infant’s body 1.Monitor axillary 1.Regular temperature 1. Newborn self 
thermoregulation newborn closely to temperature will temperature at least monitoring will maintains adequate
related to immature maintain temperature remain within normal every 8 hours; more identify adequate or body temperature
axillary range, 36.5- frequently for infants inadequate for 24 hours prior to
temperature control and prevent
37 degrees Celsius at high risk. thermoregulation discharge.
and decreased hyperthermia and cold
(Glass, 1999, p. 188). (Glass, 1999, p.188).
subcutaneous body fat. stress Axillary temperature
2.Provide heat/warm is good indicator of  2. Mother
2. Mother will verbalize the newborn using newborn’s surface demonstrates
possible methods of  incubators, radiant temperature (Glass, effective
Goals: heat loss & warmer, swaddling, maintenance of 
1999, p. 188).
demonstrate and skin-to-skin neutral thermal
understanding of  contact. environment within
conduction, 2.To warm the 24 hours.
Long-term: Newborn
convection, newborn and
will be able to sustain 3.Maintain thermal
radiation, & adequately maintain
adequate/normal self  evaporation within neutral environment accepted thermal 3. Mother verbalizes
thermoregulation. 12 hours. and avoid situations range (Wong, 2003, methods of possible
that might p. 371). heat loss within 12
predispose the infant hours.
3. Mother will to heat loss, such as
Short-term: Provide demonstrate cool air, drafts, 3.To maintain stable
assistance and support maintenance of a bathing, and cold body temperature of  4. Mother
to maintain neutral thermal bedding. the newborn and demonstrates proper
adequate/normal environment within decrease the skin-to skin warming
24 hours. possibility of heat technique prior to
temperature
loss through discharge.
conduction,
4. Mother will convection,
demonstrate proper radiation, &
skin-to-skin warming evaporation (Wong,
technique prior t 2003, p. 371).
discharge.