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NURSING CARE

PLAN
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Objectives; Ineffective Within 90 mins. of • Monitor • Regular After 30 mins. of


thermoregulation r/t mummifying the axillary temperature mummifying the
• acrocyanosis decrease infant, maintaining temperature at monitoring will infant, maintaining
• Capillary refill subcutaneous body thermal neutral least every 3 identify adequate thermal neutral
time of 3 hours or as or inadequate
fat 20 newborn environment such environment such
seconds. necessary. thermoregulation.
hypothermia as turning off the Axillary as turning off the
• Apnea
air-conditioned, temperature is air-conditioned,
• cool pale
extremities monitoring the good indicator of monitoring the
• dry skin axillary newborn’s axillary temperature
temperature as surface as necessary the
• Temperature:
necessary body will temperature body minimize heat
35.5 C
• Dyspnea minimize heat loss, loss, warm, and dry
• To warm the
• RR:68 bpm warm, and dry skin • Provide skin
newborn and
heat/warm the adequately
newborn using maintain
incubators, accepted thermal
radiant warmer, range
and skin-to-skin
contact.
• To maintain
stable body
• Maintain temperature of
thermal neutral the newborn and
environment and decrease the
avoid situations possibility of heat
that might loss through
predispose the conduction,
infant to heat convection,
loss, such as radiation, &
cool air, drafts, evaporation
bathing, and cold
bedding.
• Drying
• Dry newborn quickly and
thoroughly and placing and
quickly and placing on a
discard the wet warm, dry
blanket. Place surface prevent
the infant under heat loss from
a pre warmed evaporation.
radiant warmer.