CLIENT INITIALS-

New Born

DATE- 6/13/13

OB/Nursery

STUDENT NAME

Nursing Student JWS

NURSING DIAGNOSIS
related to ETIOLOGY or RISK FACTORS R/T to age, patient is a newborn with immature circulatory system, inability of hypothalamus to correctly manage thermoregulation, and patient has a lack of subcutaneous brown fat to maintain temperature. evidenced by DEFINING CHARACTERISTICS

PLANNING

Nursing Problem Risk for Hypothermia

GOALS (SHORT & LONG TERM) S. patient will maintain a temperature WNL (97.5 to 100.4) during shift. S. patient will demonstrate warm dry skin with a pink color tone representing good circulation during the shift. L. parents of patient will verbalize their understanding of the importance of maintaining patients temperature to prevent hyperthermia or hypothermia.

INTERVENTION WITH JUSTIFICATION

Assess patients temperature for baseline and changes. Monitor patients temperature, appearance, and vitals every 30 mins/6X Use temperature lamp to assist patient in maintaining proper temperature. Use layered clothing to adjust for temperature. Typical clothing is one layer more than needed for adult. If need be, use blankets and clothing that has been kept in warmer. Keep patients head covered to prevent radiation heat loss. Wait for bathing until patient has a temp above 97.5 to avoid chills and heat loss. Encourage patient to feed/breast feed in order to gain glucose to produce metabolic heat. Encourage mother to have skin to skin time & wrapswaddle patient afterwards. Educate parents of S & S of patients temp change. Educate parents of their duty to ensure patient is kept at a proper temp. Educate parents on ways to manage patients temp through environment, feeding, hydration & clothing.

EVALUATION Goal met

Goal met

Goal in progress