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newborn nursing care plan with refernces

newborn nursing care plan with refernces

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Published by neuronurse

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Published by: neuronurse on Nov 23, 2009
Copyright:Attribution Non-commercial

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02/27/2014

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Student initials: RMSDate(s) of care: 05/31/08
Patient Information
Pertinent Medical History:
Baby L was born 05/28/08 @ 11:18. Delievery CS for breech. Initial Assessment: weight was 6 lb, 5 oz.(@0015, 05/31) length- 18.25” HC- 13.25”T-98.1F, resp-54; HR-66. Baby active; color is pink with olive undertones, good cry,head normocephalic,fontanelles and sutures WNL.Milia present across nose. Hair is soft, black and sparse. Eyebrows and lashespresent, eyes and ears level, nostrils equal, no flaring observed. Sucking pads present. Palate intact, good suck reflex. Eyesbright dark brown, + blink reflex, baby is responsive to sound and movement. No drooping or paralysis noted in face. Scelerabluish-white. Ears are symmetrical, well-formed. No lesions noted. Clavicles straight and intact. BL lung expansion, Lungs clearBL, nipples symmetric, flat. HR regular, no murmurs or thrills noted. Abdomen protruding, umbilical cord dry, no bleeding. Activebowel sounds x 4 quad. No inguinal bulges, femoral pulses +1/4. Genitals symmetrical; pubis dark brown and engorged, scantsmegma present within labia. Buttocks symmetric, anus patent, no dimpling at coccyx. Symmetric buttock creases. All reflexescharted as present. Apgar 8/9.
Occupation:
newborn baby
Family History
: FOC not present, great-grandmother has band.
Educational Level:
none
Religion:
none; mother is Baptist
Medications:
none
Sociocultural considerations:
family is of low socioeconomic status; may need referrals to outside agencies
ALLERGIES:
NKA
Current lab findings:
blood Type B+
DNR status:
full CPR
Current diagnostic findings:
normal, healthy newborn
 
Assessment(Supporting data) Nursing Diagnosis(NANDA diagnostic statement)Goals & Expected Outcomes(Realistic, timed, measurable) Nursing Interventions(Strategies or actions for care)Rationale for interventions(Include source and page numbers)Evaluation(Client’s response to nursing actions& progress toward achievinggoals & outcomes)
 
Subjective: Baby is calm,soothes easily, does notappear uncomfortableObjective: Baby L’s axillatemp: 98.1 F; skin warm anddry
Risk for imbalanced body temperature r/textreme of age (newbornstatus)
Infant will maintain its body temperature between97.0 and 99.0F for entireshiftAssess infant’s temp eachhour If temp is above 101F, takemeasures to bring temp tonormal range:
o
Administer antipyretics asordered
o
Monitor anddocument relatedsymptoms withspecific regard tofebrile seizures
Infants lack maturethermoregulation. Temps too highor too low can disrupt acid-base balance, causing seizures or shock.
1
Infants are at risk for febrileseizures r/t immaturethermoregulation and must besafeguarded against further sequelae.
2
Signs of neonatal seizuresinclude:
Repetitive sucking
Repeated extending of thetongue
Continuous chewing
Continuous drooling
Long pauses in breathing(apnea)
Rapid eye movements
Blinking/fluttering of eyelids
Fixation of gaze to one side
Body aligned to one side
Pedaling/steppingmovements of legs
Paddling/rowing movementsof arms
Rapid muscle jerks
3
Goal Met: Baby L’s temp. remainsWNL for entire shift
1
Cox’s Clinical Applications of Nursing Diagnosis; pg.141
2
Cox’s; pg.141
3
http://www.epilepsyfoundation.org/infants/neonatalonset.html

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