MINDANAO SANITARIUM AND HOSPITAL COLLEGE

Brgy. San Miguel, Iligan City 9200

SCHOOL OF NURSING
Ay. 2009-2010

NEWBORN HYPOTHERMIA AND

HYPERTHERMIA

SUBMITTED BY:
Syra Allison C. Dimco, BSN-2NC
Marycris A. Pagapula-an, BSN-2NB

SUBMITTED TO:
Karla B. Orbeta, RN
Systems Assessment
Integumentary Normal:
• When the is delivered, the newborn will appear cyanotic only for 24 hours.
• Color in Cuacasian infants usually pink; varies with other ethnic
backgrounds.
• Pigmentation increases after birth.
• Skin may be dry.
• Small amounts of lanugo and vernix caseosa still seen.

Hypothermia:
Inspection
• Acrocyanosis
• The newborn is chilling
Palpation
• Cold extremities

Hyperthermia:
Inspection
• The skin is pale
• Flushed skin
• Profuse sweating
Palpation
• Warm extremities
Respiratory Normal:
• The newborn’s normal respiratory rate is 30-60 breaths per minute with
short periods of apnea (<15 seconds).
• Chest and abdomen rise simultaneously; no seesaw breathing.
Inspection
• Rapid respiration
• Apnea
Auscultation
• Tachycardia
• Increased respiratory rate, greater that 60 bpm
Circulatory Normal:
• Heart rate averages 140 beats per minute at birth, with chages noted
during sleep.
• Ductus arteriosus constricts with establishment of respiratory function;
later becomes ligament (2-3 months).
Inpection
• Inpect for signs of hypoxia
• Cyanosis
• Rapid respiration
Palpation
• Cold extremities
Auscultation
• Respiratory rate greater that 60 bpm
• Tachycardia
Neurologic Reflexes present at birth:
• Rooting, sucking, and swallowing.
• Tonic neck, “fencing” attitude.
• Grasp: newborn’s fingers curl around anything placed in palm.
• Moro reflex: symmetric and bilateral abduction and extension of arms and
hands; thumb and forefinger form a C; the “embrace” reflex.
• Startle reflex: similar to Moro, but with hands clenched.
• Babinski’s sign: flare of toes when foot stroked from base of heel along
lateral edge to great toe.
Inpection
• Assess for any absence of the following reflexes for further evaluation of
the newborn’s condition.
 Anatomy and Physiology

Temperature Regulation

Temperature regulation is the maintenanace of thermal balance of the loss of heat to the
environment at a rare equal to the production of heat. Newborns are homeothermic; they attempt to
stabilize their internal (core) body temperatures within a narrow range in spite of significant temperature
variations in their enviromnment.

Thermoregulation in the newborn is closely related to the rate of metabolism and oxygen
consumption. Within a specifis environmental range called the thermal neutral zone (TNZ), the rates of
oxygen consumption and metabolism are minimal, and internal body temperature is maintained because
of thermal balance. For an unclothed full-term newborn, the TNZ range is ambient temperature of 32 to
34C (89.6-93.2F). the limits for an adult are 26 to 28C (78.8-82.4F). thus, the4 normal newborn requires
higher environmental temperature to maintain a thermoneutral environment than does the adult.

Table 1.1
Laboratory Data Normal Range
Hemoglobin 15-20 g/dL
Hematocrit 43%-61%
WBC 10,000-30,000/mm3
Neutrophils 40%-80%
Immature WBC 3%-10%
Platelets 100,000-280,000/mm3
Reticulocytes 3%-6%
Blood volume 82.3mL/kg (third day after early cord clamping)
92.6 mL/kg (third day after delayed cord
clamping)
Sodium mmol/L 124-156
Potasssium mmol/L 5.3-7.3
Chloride mmol/L 90-111
Calcium mg/dL 7.3-9.2
Glucose mg/dL 40-97

Types of Heat Loss

A newborn is at a distinct disadvantage in maintaining a normal temperature because of its larger

body suface in relation to mass and limited amount of insulating subcutaneous fat. With a body weight
approximately 5 percent of the adult’s and body surface nearly 15 percent of the adult’s, the full-term
newborn loses about four times as much ehat as an adult.

Convection

Is the loss of heat from the warm body surface to the cooler air currents. Air-conditioned rooms, oxygen
by mask, and removal from an overhead warmer increase connective heat loss of the neonate.

Radiation

Losses occur when heat transfers from the heated body surface to cooler surfaces and objects not in
direct contact with the body. The walls of a room or of an incubator are potential causes of heat loss by
radiation, even if the ambient temperature of the isolette is within the thermal neutral range for that infant.

Evaporation

Is the loss of heat incurred when water is converted to a vapor. The newborn is particularly prone to lose
heat by evaporation immediately after delivery, when the infant is wet with amniotic fluid, and during
baths.

Conduction

Is the loss of heat to a cooler surface by direct skin contact. Chilled hands, cool scales, cold examination
tables, and cold stethoscopes can cause loss of heat by conduction.
Table 1.2
Age and Weight Range of Temperature Age and Weight Range of
(oC) Temperature (oC)
0-6 hours 72-96 hours
Under 1200 g 34.0-35.4 Under 1200 g 34.0-35.0
1200-1500 g 33.9-34.4 1200-1500 g 33.0-34.0
1501-2500 g 32.8-33.8 1501-2500 g 31.1-33.2
Over 2500 (and > 36 32.0-33.8 Over 2500 (and > 36 29.8-32.8
weeks) weeks)
6-12 hours 4-12 days
Under 1200 g 34.0-35.4 Under 1500 g 33.0-34.0
1200-1500 g 33.5-34.4 1501-2500 g 31.0-33.2
1501-2500 g 32.2-33.8 Over 2500 ( and >
36 weeks)
Over 2500 (and > 36 31.4-33.8 4-5 days 29.5-32.6
weeks)
12-24 hours 5-6 days 29.4-32.3
Under 1200 g 34.0-35.4 6-8 days 29.0-32.2
1200-1500 g 33.3-34.3 8-10 days 29.0-31.8
1501-2500 g 31.8-33.8 10-12 days 29.0-31.4
Over 2500 (and > 36 31.0-33.7 12-14 days
weeks)
24-36 hours Under 1500 g 32.6-34.0
Under 1200 g 34.0-35.0 1500-2500 g 31.0-32.2
1200-1500 g 33.1-34.2 Over 2500 ( and > 29.0-30.8
36 weeks)
1501-2500 g 31.6-33.6 2-3 weeks
Over 2500 (and > 36 30.7-33.5 Under 1500 g 32.2-34.0
weeks)
36-48 hours 1500-2500 g 30.5-33.0
Under 1200 g 34.0-35.0 3-4 weeks
1200-1500 g 33.0-34.1 Under 1500 g 31.6-33.6
1501-2500 g 31.4-33.5 1500-2500 g 30.0-32.7
Over 2500 (and > 36 30.5-33.3 4-5 weeks
weeks)
48-72 hours Under 1500 g 31.2-33.0
Under 1200 g 34.0-35.0 1500-2500 g 29.5-32.2
1200-1500 g 33.0-34.0 5-6 weeks
1501-2500 g 31.2-33.4 Under 1500 g 30.6-32.3
Over 2500 (and > 36 30.1-33.2 1500-2500 g 29.0-31.8
weeks)

For this table,scopes had the walls of incubator 1-2o warmer than the ambient air temperatures. Generally
speaking, the smaller infants in each weight group will require a temperature in a higher portion of the
temperature range. Within each time range,the younger the infant, the higher temperature required.
Heat Production

Upon being exposed to a cool environment, the neonate requires additional heat. Several
sources of heat production, or thermogenesis, are available, icluding increased basal metabolic rate,
muscular activity, and chemical thermogenesis (also referred as nonshivering thermogenesis) mediated
through the release of catecholamines.

Nonshivering Thermogenesis

Nonshivering thermogenesis is unique to the newborn’s stores of brown adipose tissue. Brown
adipose tissue (BAT), or brown fat, is the primary source of heat in the cold-stressed newborn. It first
appears in the fetus at 26-30 weeks of gestation and continues to increase in supply until 2-5 weeks after
the birth of a full-term neonate, unless it is depleted by cold stress. Brown fat is deposited in the
midscapular area, around the neck, and in the axillas, with deeper placement around the trachea,
esophagus, abdominal aorta, kidneys, and adrenal glands. It continues 2 percent to 6 percent of the
newborn’s total body weight. Brown fat receives its name from its dark color, which is due to enriched
blood supply, dense cellular content, and abundant nerve endings.

Brown Fat

The structures of brown and white fat cells differ, as do their function. In brown fat, the large
numbers of fat cells facilitates the speed with which triglycerides can be metabolized to produce heat.
Energy is provided by the presence of glycogen and large numbers of mitochondria releasing adenosine
triphosphate (ATP) for rapid metabolic turnover and production of heat. In addition, brown fat possesses a
rich blood supply to enhance the distribution of heat throughout the body, and a nerve supply for initiation
of metabolic activity. This type of metabolism is specific to the newborn. The brown fat is metabolized and
used within several weeks after birth.

Chemical Thermogenesis

Chemical thermogenesis occurs when skin receptors perceive environmental temperature

changes and transmit sensations to the CNS, which in turn stimulates the sympathetic nervous system.
Release of norepinephrine by the adrenal gland and at a local nerve endings in the brown fat causes the
metabolism of the triglycerides to fatty acids, thereby releasing heat to be distributed to the body. Brown
fat is a major producer of heat for the cold-stressed neonate because of its greater heat production
capacity.

Response to Heat

Sweating is the usual initial response of the newborn to hyperthermia. The neonate has six times
as many sweat glands as the adults, but the newborn’s activity level is one-third than of the adult. The
glands have limited function until after the fourth week of extrauterine life. Dissipation of heat is
accomplished by peripheral vasodilation and evaporation of insensible water loss. Oxygen consumption
and metabolic rate also increases in response to hyperthermia.
 Pathophysiology

Hypothermia

Shivering, a form of muscular activity common in the adult, is rarely seen in the newborn,
although it has been observed at ambient temperatures of 15C (59F) or less. If shivering does appear, it
means the infant’s metabolism rate has alreadt doubled and the extra muscular activity does little to
produce needed heat.

After being exposed to cold, thermographic studies of newborns show an increase in the skin
heat over the brown fat deposits in the neonate between 1 and 14 days of age. If the drown fat supply has
been depleted, the metabolis response to cold will be limited or lacking. An increase in metabolism as a
result of hypothermia results in increase oxygen consumption.

After birth,the highest losses of heat generally result from radiation and convection because of
the newborn’s large body surface compared with weight, and from thermal conduction because of the
marked difference between core temperature and skin temperature.

Hypethermia

Since the newborn’s systems are still immature, peripheral vasodilation is not an effective
mechanism as well as dissipation of heat is unlikely not successful that’s why newborn’s metabolic rate
have to increase which causes more complications.

See the flow charts....

 Flow Chart:

Newborn Hypothermia and Hyperthermia

Precipitating Factors Predisposing Factors

-Exposure to environmental factors -Inadequate prenatal
care
• Cold -Preterm infants
• Too Hot -Sick babies
-Exposure to pathogens -Low birth weight and
less
BAT stores

↓
Immature thermoregulation
↓
Exposure to environmental factors
↓
body’s response to the presence
Radiation, Conduction, Convection, Overheating of pathogens

and Evaporation ↓ ↓
↓ ↑ body temperature (systemic inflammatory
response)
Heat Transfer ↓
↓
The newborn experiences heat loss Peripheral Vasodilation ↑ perspiration ↑ Metabolic rate
(↓ temperature) ↓ ↓ ↓
↓ Dissipation of heat ↑ loss of body fluids ↑ O2 consumption

Peripheral Vasoconstriction ↓ through sweating and ↑ glucose

use
↓ Further ↑ in body temp. ↓
Dehydration
NST ↑ Metabolic rate
↓
Metabolism of
Brown Fat ↑ O2 ↑ glucose use
↓ consumption ↓
Depletion of ↓ depletion of
brown fat ↓ surfactant glycogen stores
production

Further ↓ in body temperature

Signs and Symptoms

Respiratory Endocrine Circulatory Integumentary

-dyspnea -hypoglycemia -hypoxia -↓ body temperature
-apnea -hypoxemia -↑ body temperature
-tachycardia -metabolic acidosis -pallor
-cold extremities
-acrocyanosis
-profuse sweating
-warm flushed skin
Legend:

Hypothermia-
Hyperthermia By: Syra Allison Dimco

Nursing Diagnosis: Ineffective thermoregulation: Hypothermia r/t immature compensation for changes in the environmental temperature.
Cues Objective
Subjective cues: STO:
Within 10-30 minutes of providing
immediate nursing care to the
newborn such as, immediately
drying the newborn, covering it
with warm linen and putting it into
preheated radiant warmer or
incubator as necessary, newborn
will be prevented of losing too
much heat, as evidence by
absence of chilling and cyanosis.
Objective cues: LTO:
-Temp.- Higher than normal Within 2-3 days of rendering
range which is 36.5-37 oC nursing care to the newborn such
-RR- Higher than normal as, maintaining warm
range which is 30-60 BPM environment within newborn’s
-HR- Higher than normal capacity to adopt through skin-to-
range which is 120-160 skin contact with the mother every
BPM 1-2 hours a day, putting it in the
-Cyanosis incubator as necessary with
-Cold extremities proper monitoring, newborn will
-Chilling be able to maintain and regulate
body temperature within expected
normal range.
Nursing Care Plan (NCP)
Nursing Intervention
Independent:
Note contributing factors, (e.g.
premature neonate, CNS trauma,
near-down problems, sepsis,
hypothyroidism.)
Assess environment for possible
sources of heat loss through
evaporation, conduction, convection,
or radiation.
Check radiant heat source or isolette.
Prewarm all blankets and equipment
that come in contact with the
newborn.
Immediately dry the newborn
thoroughly with clean soft preferably
warm towel. Use another warm towel
to wrap the baby in two layers.
Ensure that the head is well covered
and avoid the newborn contact with
cold surfaces.
Put the newborn under preheated
radiant warmer or in the incubator as
necessary.
Rationale Evaluation
After providing care to the newborn
such as maintaining good warm
To know any underlying problems. environment within newborn’s
capacity to adopt and proper
monitoring of temperature with
proper parents instruction, both
short and long term objectives were
To minimize risk of heat loss. achieved as evidence by newborn is
able to maintain and regulate body
temperature within expected normal
range.
To ensure maintenance of
appropriate temperature of the
environment
To minimize heat loss.
To prevent rapid heat loss through
evaporation.
To minimize heat loss.
Assists in maintaining the
temperature of infant. To help the
newborn regulate and maintain
normal body temperature.
Monitor temperature frequently (at To know possible significant changes
least 3 hours), blood pressure, heart or to identify deviations that could
and breathing rates, and oxygen suddenly occur.
levels.

Assess respiratory status effort. Rate and tidal volume are reduced
when metabolic rate decreases and
respiratory acidosis occurs.

Auscultate lungs, noting adventitious Pulmonary edema, respiratory

sounds. infection, and pulmonary embolus are
possible complications of
hypothermia.

Monitor heart rate and rhythm. Cold stress reduces peacemaker

function, and bradycardia
(unresponsive to atropine), atrial
fibrillation, atrioventricular blocks, and
ventricular tachycardia can occur.

Monitor blood pressure, noting Hypotension can occur due to

hypotension. vasoconstriction and shunting of fluids
as a result of cold injury effect on
capillary permeability.

Measure urine output. Oliguria can occur due to low flow

state and/or following hypothermic
osmotic diuresis.

Monitor laboratory studies, such as Respiratory and metabolic acidosis,

ABCs, CBC, and electrolytes. increased hematocrit, decreased
white blood cell count may manifest.

Maintain patent airway, assist in To prevent further heat loss.

intubation if indicated, and provide
heated humidified oxygen when used.

Turn off warming blankets when To avoid hyperthermia situation since

temperature is within1-3 degrees to the infant is still cannot regulate its
prevent hyperthermia. own temperature.
Encourage kangaroo care (mother To provide warmth and contact which
holds the infant underneath her aid in parent-infant attachment.
clothing skin-to-skin and upright Assists in maintaining the
between her breast) temperature of infant.

Avoid bathing the infant if temperature To prevent cold stress.

is not yet stable.

Educate parents on how to maintain a To promote newborn’s adjustment.

neutral thermal environment,
including importance of keeping the
newborn warm with a cap and double-
wrapping with blankets and changing
them frequently to keep dry.

(If the infant can be already bath)

In bathing the baby:
- Ensure before giving bath
that temperature is normal.
- Use warm room and warm
water.
- Bathe quickly and gently.
- Dry quickly and thoroughly
from heat to toe.
- Wrap in a warm dry towel.
- Dress and wrap infant, use a
cap on the head.
- Place infant close to the
mother.

Collaborative:

Refer to social services or a dietitian Preventive approaches decrease the

as appropriate. risk of heat loss or hypothermia.

Nursing Diagnosis: Ineffective thermoregulation: Hyperthermia r/t immature compensation for changes in the environmental temperature and/or presence of endogenous
pathogens.
Cues Objective
Subjective cues: STO:
Within 10-30 minutes of providing
immediate nursing care to the
newborn such as, providing good
temperature by not over wrapping
the baby and avoiding it expose
with too much heat, newborn will
be prevented of gaining too much
heat as evidence by absence of
profuse sweating and irritability.
Objective cues: LTO:
-Temp.- Higher than normal Within 2-3 days of proving nursing
range which is 36.5-37 oC care to the newborn such as
-RR- Higher than normal maintaining good temperature
range which is 30-60 BPM (not too hot) with proper aseptic
-HR- Higher than normal technique in giving care, newborn
range which is 120-160 will be prevented of developing
BPM infection as evidence by absence
-Warm and clammy skin of fever.
-Sweating
-Pallor
-Tachycardia
Nursing Care Plan (NCP)
Nursing Intervention
Independent:
Assess neurological response, noting
level of consciousness and orientation
and reaction to stimuli, reaction of
pupils, and presence of posturing or
seizures.
Assess environment for possible
sources of heat gain through
evaporation, conduction, convection,
or radiation.
Monitor temperature frequently (at
least 3 hours), blood pressure, heart
and breathing rates, and oxygen
levels.
Monitor heart rate and rhythm.
Monitor respirations. Auscultate
breath sounds, noting adventitious
sounds such as crackles.
Monitor, record, and assess all
sources of fluid loss such as urine,
and insensible losses.
Note presence/absence of sweating
as the newborn’s body attempts to
increase heat loss by evaporation,
Rationale Evaluation
After maintaining core temperature
within newborn’s capacity to adopt
For proper assessment to the severity and proper observation of aseptic
of problem. technique in giving care both short
and long term objectives were
achieved as evidence by newborn is
able to maintain and regulate body
temperature within expected normal
To minimize risk of heat gain. range and is prevented of
developing infection.
To know possible significant changes
or to identify deviations that could
suddenly occur.
Dysrhythmias and ECG changes are
common due to electrolyte imbalance.
Hyperventilation may initially be
present but ventilatory effort may
eventually be impaired due to
immature system.
That could indicate oliguria,
potentiates fluid and electrolyte
losses.
Evaporation is decreased by
environmental factors of high humidity
and high ambient temperature, as
conduction, and diffusion. well as body factors producing
inability to sweat or sweat gland
dysfunction (e.g. spinal cord
transection.)

Provide tepid sponge bath but avoid May help reduce fever. Ice water or
using alcohol as solution. alcohol may cause chills actually
elevating temperature.

Promote surface cooling by To promote heat loss in the body.

undressing or not double-wrapping
the infant.

Observe aseptic technique in giving To prevent development or further

care to the newborn with proper development of infection.
handling.

Provide tube feedings, or parenteral To meet metabolic demands.

nutrition.

Provide supplemental oxygen. To offset increased oxygen demand

and consumption.

Avoid infant contact with hot surfaces. To prevent further heat gain.

Instruct parents to avoid leaving the To prevent heat injury/death.

newborn unattended.

Monitor fluid intake, through IV. To prevent dehydration.

Educate parents about that To prevent too much heat gain.

importance not double wrapping the
newborn.

Monitor laboratory studies such as May reveal tissue degeneration,

ABCs, electrolytes, cardiac and liver myoglobinuria, proteinuria, and
enzymes, glucose urinalysis, and hemoglobinuria.
coagulation profile.

Collaborative:
Refer to social services or a dietitian Preventive approaches decrease the
as appropriate. risk of heat loss or hypothermia.

Nursing Diagnosis: Ineffective breathing pattern r/t increase respiratory drive secondary to increased O2 consumption.
Cues Objective
Subjective cues: STO:
Within 10-30 minutes of providing
immediate nursing care to the
newborn such as, administering
1-2 L of O2 via nasal cannula with
proper monitoring of RR and
breathing pattern, newborn will be
able to attain normal breathing
pattern as evidence by absence
of apnea and dyspnea.
Objective cues: LTO:
Within 2-3 days of proving nursing
-Temp.- Higher than normal care to the newborn such as
range which is 36.5-37 oC proper maintenance of oxygen
-RR- Higher than normal and maintaining neutral thermal
range which is 30-60 BPM environment to reduce oxygen
-HR- Higher than normal consumption, newborn will be
range which is 120-160 able to maintain normal breathing
BPM Pattern and maintain respiratory
-Dyspnea rate within expected normal
-Slightly cyanotic range.
Nursing Care Plan (NCP)
Nursing Intervention
Suction secretions properly, mouth
and nasopharynx with bulb syringe or
using the suction machine with
suction catheter as needed.
With mechanical suction, limit each
suctioning attempt to 10-15 seconds,
with sufficient time in between
attempt.
Assess gestational age and risk
factors for respiratory distress.
Anticipate need for bag and mask
setup and wall suction.
Assess the respiratory effort.
Observe for cues (grunting, shallow
respirations, tachypnea, apnea,
tachycardia, central cyanosis,
hypotonic, increased effort).
Assess skin color.
Maintain slight head elevation.
Monitor oxygen saturation level via
pulse oximetry.
Rationale Evaluation
To provide patent airway and After 10-30 mins. of providing
aspiration of fluid. supplemental oxygen with proper
monitoring of RR as well as the
breathing pattern, newborn is able
to attain normal breathing pattern,
To allow oxygenation. and within 2-3 days of rendering
nursing care, newborn is able to
maintain normal breathing pattern
and normal respiratory rate, within
expected normal range.
To allow early detection.
To allow for prompt intervention
should respiratory status continue to
worsen.
To identify changes.
To identify newborn’s need for
additional oxygen.
To evaluate tissue perfusion.
To prevent upper airway obstruction.
To provide objective indication of
perfusion status.
Provide supplemental oxygen as To ensure adequate tissue
indicated and ordered. oxygenation.

Assist with any ordered diagnostic To determine effectiveness of

test, such as chest x-ray and arterial treatments.
blood gases.

Maintain a neutral thermal To reduce oxygen consumption.

environment.

Monitor hydration status. To prevent fluid volume deficit or

overload.

Position infant right side after feeding. To prevent aspiration.

Explain all events and procedures to To help alleviate anxiety and promote
the parents. understanding of newborn’s condition.

Inform parents that the rapid Providing information helps to allay

respiratory rate is common in some parent’s anxieties and fears.
newborns after birth because
increase oxygen demand.

Monitor newborn’s temperature and Newborns have difficulty conserving

keep him/her warm via radiant body heat. Exposure to cold
warmer. Wrap the newborn loosely in increases the metabolic rate,
a blanket and place a cap on his/her increasing the need for oxygen and
head. further increasing the respiratory rate.

Nursing Diagnosis: Fluid volume deficit r/t insensible fluid loss and profuse sweating.
Cues Objective
Subjective cues: STO:
Within 10-30 minutes of providing
supplemental fluids to the
newborn as well as providing a
thermo neutral environment,
newborn will be prevented of too
much fluid loss as evidence by
the absence of sweating and
adequate urinary output.
LTO:
Objective cues:
Within 2-3 days of proving nursing
care to the newborn such as
-Temp.- Higher than normal continuation of providing
range which is 36.5-37 oC supplemental fluids and proper
-RR- Higher than normal monitoring of intake and output,
range which is 30-60 BPM newborn will be able to maintain
-HR- Higher than normal fluid and electrolytes balance as
range which is 120-160 evidence by absence of
BPM dehydration.
-Tachycardia
-dry skin
-Profuse sweating
-Pallor
-Dry lips
-Slow capillary refill
Nursing Care Plan (NCP)
Nursing Intervention
Independent:
Note infant’s level of dehydration, and
mentation.
Provide supplemental fluids.
Monitor and record vital signs (temp,
RR, HR) closely for at least every 3-4
hours interval.
Auscultate blood pressure, calculate
pulse pressure.
Maintain a thermo neutral
environment but not too cold.
Monitor and record intake and output
accurately. Note number, character,
and amount of stools.
Estimate/ calculate insensible fluid
losses.
Estimate insensible fluid losses; e.g.
diaphoresis. Measure urine specific
gravity; observe for oliguria.
Rationale
Provides information regarding ability
to tolerate fluctuations in fluid level
and risk for creating or failing to
respond to problem.
For immediate replacement of fluid
loss.
Tachycardia, fever can indicate
response to and/or effect of fluid loss.
Pulse pressure widens before systolic
BP drops in response to fluid loss.
To minimize O2 consumption as well
as minimize sweating.
Provides information about overall
fluid balance, and bowel control, as
well as guidelines for fluid
replacement.
To include in replacement
calculations.
To have accurate information about
fluid loss for proper replacement.
Evaluation
Within 10-30 minutes of providing
supplemental fluids to the newborn
as well as providing a thermo
neutral environment, newborn is
prevented of too much fluid loss as
evidence by the absence of
sweating and adequate urinary
output, and within 2-3 days of
proving nursing care to the newborn
such as continuation of providing
supplemental fluids and proper
monitoring of intake and output,
newborn is able to maintain fluid
and electrolytes balance as
evidence by absence of
dehydration.
Observe for excessively dry skin and Indicates excessive fluid loss/
mucous membranes, decreased skin resultant dehydration.
turgor, slowed capillary refill.

Note generalized muscle weakness or To know other possible health

cardiac dysrhythmias. problems such as intestinal loss.

Weigh daily, as indicated, and To know any improvements or the

evaluate changes as they relate to severity of problem,
fluid status.

Educate parents about the infant’s Proper information to the concerned

situation or condition. parents will reduce anxiety.

Collaborative:

Administer parenteral fluids as Loss of fluids really requires fluid

indicated. replacement to correct losses.

Determines replacement needs and

Monitor laboratory results e.g. effectiveness of the therapy.
electrolytes, acid-base balance.

Nursing Diagnosis: Ineffective tissue perfusion r/t imbalanced O2 supply and demand
Cues Objective
Subjective cues: STO:
Within 10-30 minutes of providing
immediate nursing care to the
newborn such as, administering
1-2 L of O2 via nasal cannula with
proper monitoring of RR and
breathing pattern, as well as
providing neutral thermal
environment, newborn will show
improvements in condition as
evidence by normal breathing
pattern.
Objective cues:
LTO:
Within 1-2 days of rendering
nursing care such as
maintenance of oxygen as
necessary and proper core
temperature, newborn will be able
to maintain the expected outcome
as evidence by normal breathing
pattern and absence of
weakness.
Nursing Care Plan (NCP)
Nursing Intervention
Independent:
Immediately provide supplemental
oxygen 1-2 L or as necessary.
Determine factors related to the
infant’s situation or condition.
Note presence of conditions/situations
that can affect multiple systems (e.g.
brain injury, sepsis, systemic lupus,
etc.).
Evaluate for signs of infection.
Maintain patent airway.
Note customary baseline data (e.g.
usual BP, weight, mentation, ABGs,
and other appropriate laboratory
study.)
Determine presence of visual,
sensory/motor changes.
Measure circumference of
extremities, as indicated
Assess lower skin extremities, noting
Rationale
To promote proper breathing.
To have an appropriate idea of the
proper intervention that should be
given.
To know any possible underlying
complications.
The infant’s immune system is still not
well developed, thus it is prone to
infection.
To promote oxygenation.
Provides comparison with current
findings.
Suggestive of a transient ischemic
attack.
Useful in identifying edema in
involved extremity.
For more information.
Evaluation
Within 10-30 minutes of providing
immediate nursing care to the
newborn such as, administering 1-2
L of O2 via nasal cannula with
proper monitoring of RR and
breathing pattern, as well as
providing neutral thermal
environment, newborn was able to
show improvements in condition as
evidence by normal breathing
pattern, and within 1-2 days of
rendering nursing care such as
maintenance of oxygen as
necessary and proper core
temperature, newborn is able to
maintain the expected outcome as
evidence by normal breathing
pattern and absence of weakness.
skin texture; absence of body hair:
presence of edema.

Measure capillary refill; palpate for Result less than 0.9 indicates need
presence/absence and quality of for more aggressive preventive
pulses. Calculate ankle-brachial index interventions to manage.
(ABI), as appropriate.

Determine usual voiding pattern; For proper overview of the infant’s

compare with current situation. condition.

Collaborative:

Administer medication as indicated. To promote further improvements to

the infants condition.

By: Syra Allison Dimco

 PATHOPHYSIOLOGY OF NEWBORN HYPOTHERMIA

Precipitating Factors Predisposing factors

Environmental factors -sick babies

-Convection -normal term babies
-Convection -preterm babies
-Radiation -low weight babies
-Evaporation
Immature Thermoregulation

Heat transfer

Decrease body temperature

Non shivering thermogenisis, vasoconstriction, increase metabolic rate

O2
Metabolism Increase use
of brownfat consumption/
of glycogen
demand

Depletion of Decrease
brownfat surfactant
production Depletion of
glycogen stores

Increase thermal insulation

Further decrease in temp.

S/Sx

Respiratory Cardio. Lymphatic Endocrine

-apnea -tachycardia -metabolic -hypoglycemia
Circulatory -dyspnea Neuro.
acidosis
-acrocyanosis -Tachypnea -lethargy
-cool, pale -increase
extremities respiratory rate
-hypoxia
-slow capillary
refill

By: Marycris A. Pagapula-an


Problem Identified: Chilling
Nursing diagnosis: Risk for altered body temperature r/t immature compensation to environmental factors 20 newborn hypothermia
Cause Analysis: The preterm newborn has a great deal of difficulty attaining body temperature because she has a relatively large surface area per kilogram of body weight. In
addition, because the infant does not flex the body well but remains in an extended position. Rapid cooling from evaporation is likely to occur.
CUES OBJECTIVES
Subjective: STO:
Within 30 min of wrapping the
infant with warm blanket, cover
the infants head, maintaining
Objective: thermal neutral environment
• Lethargic such as turning off the air-
• acrocyanosis conditioned there will be a
• Capillary refill time of 3 decrease of heat loss through
seconds. conduction, convection,
• Apnea radiation, & evaporation
• cool pale extremities
LTO:
• dry skin
• Temperature: 35.5 C
Within 2 hour of providing the
• Tachycardia use of incubators, radiant
• Dyspnea
warmer, and skin-to-skin contact
• RR:68 bpm the body temperature 35.5C will
maintain to its normal range from
36.5-37.5
NURSING CARE PLAN
NURSING INTERVENTIONS
Independent:
• Rub both hand before
touching the newborns body
• Wrap infant snugly in a
warmed blanket or provide skin-
to-skin contact.
• Place infant in a preheated
environment (under radiant
warmer).
• Place infant on a padded,
covered surface.
• Monitor axillary temperature
at least every 8 hours; more
frequently for infants at high risk.
• Postpone bath if there is any
question regarding stabilization of
body temperature.
• Dress infant in a shirt and
diaper and swaddle in a blanket
RATIONALE
• To decrease the possibility
of heat loss through conduction.
• Helps conserve heat in the
body
• Maintains thermoneutral
environment, helps prevent cold
stress.
• To maintain stable body
temperature and decrease the
possibility of heat loss through
conduction.
• Regular temperature
monitoring will identify adequate
or inadequate thermoregulation.
Axillary temperature is good
indicator of newborn’s surface
temperature
• Bathing the infant can cause
heat loss through evaporation.
• To prevent from chilling and
decrease the possibility of heat
EVALUATION
STO:
After 30 min of wrapping the
infant with warm blanket,
cover the infants head,
maintaining thermal neutral
environment such as turning
off the air-conditioned there is
a decrease of heat loss
through conduction,
convection, radiation, &
evaporation
LTO:
After 1 hour of providing the
use of incubators, radiant
warmer, and skin-to-skin
contact the body temperature
35.5C will maintain to its
normal temperature range
from 36.5-37.5
 or cover with blanket.
• Cover the infants head
• Keep infant away from drafts,
air conditioning vents, or fans.
Reference: Wong’s Nursing Care of Infants and Children Vol.1 & 2
loss through convection.
• The infant’s head provides a
large surface area for heat loss
• To maintain stable body
temperature of the newborn and
decrease the possibility of heat
loss through conduction,
convection, radiation, &
evaporation
Problem Identified: Chilling
Nursing diagnosis: Ineffective thermoregulation r/t decrease subcutaneous body fat 20 newborn hypothermia
Cause Analysis: The preterm infant has little subcutaneous fat for insulation and poor muscular development does not allow the child to move actively as the older infant does to
promote heat. The preterm infant also has limited amount of brown fat; special tissue present in newborns to maintain body temperature. (Maternal and Child Health Nursing, 4th
Ed. By Pillitteri,)
CUES OBJECTIVES
Subjective: STO:
Within 30 mins. of mummifying
the infant, maintaining thermal
neutral environment such as
Objective: turning off the air-conditioned,
• Lethargic monitoring the axillary
• acrocyanosis temperature as necessary body
• Capillary refill time of 3 will minimize heat loss, warm,
seconds. and dry skin
• Apnea
• cool pale extremities
• dry skin
LTO:
• Temperature: 35.5 C
• Dyspnea
Within 2 hour of providing the
• RR:68 bpm use of incubators, radiant
warmer, and skin-to-skin contact
the body temperature 35.5C will
maintain to its normal range from
36.5-37.5
NURSING INTERVENTIONS
Independent:
• Monitor axillary temperature
at least every 3 hours or as
necessary.
• Provide heat/warm the
newborn using incubators, radiant
warmer, and skin-to-skin contact.
• Maintain thermal neutral
environment and avoid situations
that might predispose the infant to
heat loss, such as cool air, drafts,
bathing, and cold bedding.
• Dry newborn thoroughly and
quickly and discard the wet
blanket. Place the infant under a
pre warmed radiant warmer.
• Avoid placing infant on cold
surface or using cold instrument
in assessment.
• Ambient temperature of the
room where the newborn is kept
should be monitored
RATIONALE
• Regular temperature
monitoring will identify adequate
or inadequate thermoregulation.
Axillary temperature is good
indicator of newborn’s surface
temperature
• To warm the newborn and
adequately maintain accepted
thermal range
• To maintain stable body
temperature of the newborn and
decrease the possibility of heat
loss through conduction,
convection, radiation, &
evaporation
• Drying quickly and placing
and placing on a warm, dry
surface prevent heat loss from
evaporation.
• Cold surface and instrument
increase heat loss by conduction
• To prevent excessive
cooling.
EVALUATION
STO:
After 30 mins. of mummifying
the infant, maintaining thermal
neutral environment such as
turning off the air-conditioned,
monitoring the axillary
temperature as necessary the
body minimize heat loss,
warm, and dry skin
LTO:
After 1 hour of providing the
use of incubators, radiant
warmer, and skin-to-skin
contact the body temperature
35.5C maintain to its normal
temperature range from 36.5-
37.5
 • Mummify and use thick
blankets to cover the patient
• Teach the mother about the
infant’s need for warmth and to
keep the infant’s head covered
• Helps conserve heat in the
body
• The infant’s head provides a
large surface area for heat loss

• Teach family members about:

• -signs and symptoms of

altered body temperature, such • Careful teaching allows
as cool extremities. family members to take an active
• -factors in home that role in maintaining the neonate’s
contribute to neonatal heat loss health.
and ways to minimize heat loss
• -importance of contacting a
health care provider when
problems related to temp
regulation

Reference: Wong’s Nursing Care of Infants and Children Vol.1 & 2

Problem Identified: difficulty of breathing
Nursing diagnosis: Ineffective breathing pattern r/t decrease production of lung surfactant 20 to newborn hypothermia
Cause Analysis: A newborns lung is structurally underdeveloped for postnatal life. To add, the premature delivery and the inadequate pulmonary surfactant. A deficiency in
surfactant, which functions to decrease the surface tension within the alveoli. Without surfactant, the infant experiences decreased pulmonary compliance, ventilation perfusion
mismatching, and significant increase in the work of breathing. Gelli’s and (Kagan’s Current Pediatric Therapy by Burg Ingelfinger p. 261)

CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: STO:
Within 30 minutes of positioning
the infant to the right side,
Objective: suction mouth and nasopharynx
• RR:68 bpm with bulb syringe as needed RR
• Lethargic will decrease from 68- 63bpm
• acrocyanosis
• Capillary refill time of 3
seconds. LTO:
• apnea
Within 1 hour of administering
• cool pale extremities
oxygen as ordered RR will be in
• dry skin
the normal range of 30-60bpm
• Temperature: 35.5 C and manifest an increase in
• dyspnea oxygenation as evidenced of
normal skin color, pinkish
mucosa, good capillary refill and
good breathing pattern.
INDEPENDENT: STO:
• Monitor/ assess RR as • assessment provides
necessary. information about neonate’s After 30 minutes of positioning
ability to initiate and sustain an the infant to the right side,
effective breathing pattern suction mouth and
nasopharynx with bulb syringe
• Suction mouth and • May be necessary to as needed RR decreases
nasopharynx with bulb syringe as maintain airway patency from 68- 63bpm
needed. especially in infant receiving
controlled ventilation.
LTO:
• Even a slight increase or
• Maintain optimal body decrease in environmental After 1 hour of administering
temperature by mummifying the temperature can lead to apnea. oxygen as ordered RR is in
the normal range of 30-60bpm
infant.
and experience no apnea.
• To facilitate breathing
• Avoid constricting clothing or
bedding
• to prevent aspiration.
• Position infant on right side
after feeding.
• to ensure child does not slide
• Check child's position down to avoid compressing the
frequently. diaphragm.

Collaborative: • Facilitates proper oxygen in

the blood.
• Administer oxygen as ordered via
nasal cannula or mask .
Reference: Wong’s Nursing Care of Infants and Children Vol.1 & 2

Problem Identified: Ineffective tissue perfusion

Nursing diagnosis: Ineffective tissue perfusion r/t decrease O2 saturation in the blood 20 newborn hypothermia
Cause Analysis: Decrease resulting in the failure to nourish the tissues at the capillary level. Reduced arterial blood flow causes decreased nutrition and oxygenation at the
cellular level. (Maternal and Child Health Nursing, 4th Ed. By Pillitteri,)

CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: Independent: STO:

STO:
Within 1-2hrs of giving nursing
intervention such as checking
peripheral pulses every 4 hrs,
elevate the head of the bed 30
degrees to promote circulation to
lower extremities the peripheral
Objective: pulses will remain present.
• RR:68 bpm
• Lethargic LTO:
• acrocyanosis
• Capillary refill time of 3 Within 5hrs of administering
seconds. supplemental oxygen as ordered
• apnea the pt. will experience adequate
tissue perfusion and cellular
• cool pale extremities
oxygenation.
• dry skin
• Temperature: 35.5 C
• dyspnea
• Assess for possible
causative factors related to
temporarily impair arterial blood
flow.
• Monitor pulses for rate,
rhythm and capillary refill time.
• Elevate the head of the bed
30 degrees.
• Position neonate to the right
side.
• Check child's position
frequently.
• Maintain environmental and
body warmth without overheating.
• Early detection of cause
facilitates prompt, effective
treatment.
• Assessment is needed for
ongoing comparisons; loss of
peripheral pulses must be
reported or treated immediately.
• To promote circulation to
lower extremities,
• This promotes optimal lung
ventilation and perfusion. The
patient will experience optimal
lung expansion in upright
position.
• To ensure child does not
slide down to avoid compressing
the diaphragm.
• Prevents vasoconstriction
and air in maintaining circulation
and perfusion.
After 1-2hrs of giving nursing
intervention such as checking
peripheral pulses every 4 hrs,
elevate the head of the bed
30 degrees to promote
circulation to lower extremities
the peripheral pulses remain
present.
LTO:
After 5hrs of administering
supplemental oxygen as
ordered the pt. experience
adequate tissue perfusion and
cellular oxygenation.

• Changes may reflect

 • Note changes in level of eliminated perfusion in the CNS.
consciousness (seizures activity)
development of sensory/motor
deficit.

Collaborative: • To determine oxygen supply

in the body.
• Monitor Oxygen saturation
(e.g. pulse oximeter)
• Facilitates proper oxygen in
the blood.
• Administer oxygen as
ordered via nasal cannula or
mask.

Reference: Wong’s Nursing Care of Infants and Children Vol.1 & 2

Problem Identified: Hypotension
Nursing diagnosis: Decrease cardiac output r/t vasoconstriction 20 newborn hypothermia
Cause Analysis: Constriction of the peripheral blood vessels will alter the flow of blood to perfuse the different cells of the body. (Maternal and Child Health Nursing, 4th Ed. By
Pillitteri,)
CUES OBJECTIVES
Subjective: STO:
Within 3-4 hrs of rendering
effective nursing interventions
such as provide pre-warm
blanket, keep the baby covered
at all times and put the baby
Objective: under radiant warmer the skin
• RR:68 bpm will remain warm and dry.
• Lethargic
• acrocyanosis
• Capillary refill time of 3 LTO:
seconds.
• apnea Within 5-8hrs of rendering
effective nursing interventions
• cool pale extremities
such as administering
• dry skin
supplemental oxygen as ordered
• Temperature: 35.5 C
the cardiac status will be
• dyspnea stabilize and will maintain
adequate cardiac output.
NURSING INTERVENTIONS
Independent:
• Monitor the neonate’s body
temperature.
• Note skin or pallor, cyanosis.
• Observed skin color,
moisture, temperature, and
capillary refill time.
• Keep the baby out contact
with cold surfaces.
• Keep the baby covered at all
times possible. Use a pre warmed
blanket.
• Put the baby under radiant
warmer when temperature
indicates
• Cover infant’s head.
Collaborative:
• Monitor Oxygen saturation
RATIONALE
• To determine the need for
intervention and the
effectiveness of therapy.
• Pallor is indicated of
diminished peripheral perfusion
and decrease cardiac output.
• Presence of pallor: cool,
moist skin; and delays capillary
refill time may be due to
peripheral vasoconstriction.
• Baby will transfer body heat
to a cooler surface.
• This decreases the
convection heat loss.
• To warm the newborn and
adequately maintain accepted
thermal range
• The infant’s head provides a
large surface area for heat loss
• To determine oxygen supply
EVALUATION
STO:
After 3-4 hrs of rendering
effective nursing interventions
such as provide pre-warm
blanket, keep the baby
covered at all times and put
the baby under radiant
warmer the skin remains
warm and dry.
LTO:
After 5-8hrs of rendering
effective nursing interventions
such as administering
supplemental oxygen as
ordered the cardiac status
was stabilize and will maintain
adequate cardiac output.
 (e.g. pulse oximeter) in the body.

• Administer oxygen as • Facilitates proper oxygen in

ordered via nasal cannula or the blood.
mask.

Reference: Wong’s Nursing Care of Infants and Children Vol.1 & 2

By: Marycris A. Pagpapula-an

References:
Internet:
http://family.go.com/parentpedia/baby/milestones-development/baby-grasping/

http://www.babyworld.co.uk/information/pregnancy/glossary/a.asp

http://www.rwjuh.edu/health_information/centers_pregnancy_lvl2hrn.html

http://allnurses.com/general-nursing-student/newborn-nursing-diagnosis-346647.html

http://books.google.com.ph/books?
id=bsiO_GbZpgYC&pg=PA122&lpg=PA122&dq=newborn+hyperthermia&source=bl&ots=Rh
ByQOaxUp&sig=nkP-3r7ci4_q8C0b59JkS0Hbdq0&hl=tl&ei=H3skS4-
yJZeXkQWosrSnAw&sa=X&oi=book_result&ct=result&resnum=6&ved=0CCQQ6AEwBTge#
v=onepage&q=newborn%20hyperthermia&f=false

http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/MSM_97_2/en/

http://books.google.com.ph/books?
id=bsiO_GbZpgYC&pg=PA122&lpg=PA122&dq=newborn+hyperthermia&source=bl&ots=Rh
ByQOaxUp&sig=nkP-3r7ci4_q8C0b59JkS0Hbdq0&hl=tl&ei=H3skS4-
yJZeXkQWosrSnAw&sa=X&oi=book_result&ct=result&resnum=6&ved=0CCQQ6AEwBTge#
v=onepage&q=newborn%20hyperthermia&f=true

Books
Maternal Newborn Nursing a Family Approach
By: Sally B. Olds
Marcia L. London
Patricia A. Ladwig

Nurse's Pocket Guide Edition 11

By: Marilynn Doenges
Mary Frances Moorhouse,
Alice C. Murr

Focus on Pathophysiology
By: Barbara L. bullock, reet L. henze

Essentials of Maternity and Newborn

By: Scott Ricci