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Cues/Data Diagnosis Goals& Objectives Nursing Rationale Evaluation

Interventions
Ineffective After 8 hours of Monitor axillary Axillary The Goal was met,
S: N/A thermoregulation nursing intervention, temperature at temperature is The newborn self
related to immature The newborn monitor least every 8 good indicator maintains
temperature control closely to hours; more of newborn’s adequate body
O: Temperature of 35.5
and decreased maintain frequently for surface temperature for
subcutaneous body temperature and infants at high temperature 24 hours prior
fat. prevent risk. to discharge.
hyperthermia and
cold stress. Provide To warm the newborn The Mother
heat/warm of and adequately Demonstrates
Goals: newborn using maintain accepted effective
incubators, thermal range.
Long-term: maintenance of
Newborn will be radiant warmer, neutral thermal
able to sustain swaddling, and environment
adequate/normal skin-to-skin within 24 hours.
self contact.
thermoregulation. Mother
verbalizes
Short-term: methods of
Provide assistance Maintain thermal To maintain stable possible heat
neutral environment body temperature of
and support to loss within 12 hours.
and avoid situation the newborn and
maintain adequate
that might predispose decrease the
normal temperature. the infant to heat Mother demonstrates
possibility of heat loss
loss, such as cool air, through conduction, proper skin to skin
drafts, bathing and convection, radiation warming technique
cold beddings. and evaporation. prior to discharge.