CUES/ DATA NURSING RATIONALE GOALS/ NURSING RATIONAL EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTION E

S
Subjective: Ineffective A premature After 30 minutes INDEPENDENT: After 30 minutes
breathing lung is of nursing (1) assess RR (1) of nursing
n/a pattern structurally interventions, the and pattern assessment interventions,
related to underdevelope infant will provides goal is partially
Objective: immature d for postnatal experience an information met, the infant
neurologic life. To add, effective about experienced an
- Preterm birth and delayed the premature breathing pattern neonate’s effective
(34 wks and pulmonary delivery and as manifested by ability to breathing pattern
2days) developmen the inadequate initiate and as manifested by
- With Oxygen t pulmonary - Infant’s RR sustain an
hood surfactant. A is between effective - Infant’s
regulated at deficiency in 40 and 60 breathing RR was
10 liters per surfactant, - Infant will pattern between
minute which functions experience (2) provide (2) 40 and 60
- RR:58 cycles/ to decrease no apnea respiratory assistance - Infant
min the surface assistance as helps the experienc
- Episodes of tension within needed (oxygen newborn by ed less
apnea (6- 10 the alveoli. hood) clearing the episodes
secs) Without airway and of apnea
- O2 saturation surfactant, the promoting
of 91% infant oxygenation
experiences (3) position infant (3) lying on
diffuse on side with a the side
atelectasis, rolled blanket position
decreased behind his back facilitate
pulmonary breathing
compliance, (4) provide tactile (4)
ventilation stimulation during stimulation
perfusion periods of apnea of the
mismatching, sympathetic
and significant nervous
increase in the system
work of increases
breathing. respiration

SOURCE; Delmar’s
Gelli’s and Maternal-
Kagan’s Infant
Current Nursing
Pediatric Care Plans
Therapy by 2nd edition by
Burg Karla Luxner
Ingelfinger p. p. 223
261
 NURSING GOALS/EXPECTE NURSING
CUES/DATA RATIONALE RATIONALE EVALUATION
DIAGNOSIS D OUTCOMES INTERVENTION

         After 1 hour of
intervention, the
Subjective:  Ineffective The preterm  After 1 hour of goal is fully met.
thermoregulatio newborn has nursing intervention, The neonate
N/A n related to a great deal patient will maintain maintained a
Objective: immaturity and of difficulty normal body stable body
lack of attaining temperature from temperature at
 Gestational subcutaneous body 36.5-37.5 36 .7C
age of 34 and brown fat temperature
weeks 2/7 INDEPENDENT: evidenced by:
because she
 Current
weight: 2.0 has a 1. Staff  Monitor the  To 1. staff
kgs relatively members will neonate’s determine members
 Neurological large surface take steps to body the need kept
status: maintain temperature for neonate’s
area per
LOC: neonate’s until interventio body
kilogram of temperature
Lethargic body discharge n and the
body weight. at normal
 Capillary refill temperature effectivene
In addition, at normal ss of level.
time of 3
seconds. because the level. Pt. will therapy. neonate has
 Integumentar infant does have a and warm, dry
y Status: not flex the warm, dry skin
 pale legs, body well but skin  Drying
 Dry quickly and
Moderate remains in newborn placing and
pallor an extended thoroughly and placing on a
 cool and dry
position. quickly and warm, dry
skin
Rapid discard the wet surface
 Turgor: less
cooling from blanket. Place prevent heat
than 3 the infant loss from
seconds evaporation
under a pre
 neonate is is likely to warmed evaporation.
placed in the occur. radiant
isolation warmer.  Cold
room The preterm surface and
 Temperature: infant has instrument
35.5 C little  Avoid increase
 Mild placing infant heat loss by
subcutaneou
shivering on cold surface conduction
 Baby is s fat for or using cold
placed in an insulation instrument in
extended and poor assessment.  To
position muscular prevent
 Poor muscle development excessive
tone does not cooling.
 Labs:  Ambient
allow the temperature of
 Increased
Hemoglobin child to move the room
(198 g/l) actively as where the
 increased the older newborn is  Helps
Hematocrit infant does kept should be conserve
(0.58 g/l) monitored heat in the
to promote
 increased body
heat. The
WBC (10.3
preterm  Mummify 2. parents
x 10 d/l)
infant also and use thick  The expressed
2. parents will infant’s understandi
has limited blankets to
express head ng of
amount of cover the
understandin provides a neonate’s
brown fat; patient
g of thermoregul
special  Teach the large
neonate’s surface area atory
mother about
tissue thermoregula for heat loss disturbance
the infant’s
present in tory and
need for
newborns to disturbance thermoregul
warmth and to
and ation
maintain thermoregula keep the
body tion infant’s head
temperature. covered

 Careful
teaching
Source: allows
 Teach family family
Maternal and
members members
Child Health about: to take an
Nursing, 4th -signs and active role
Ed. By symptoms of in
Pillitteri, altered body maintainin
p.741 g the
temperature,
neonate’s
such as cool health.
extremities.

- factors in Sources:
home that Ladewig et
contribute to al.
neonatal heat Contemporar
loss and ways y Maternal-
to minimize Newborn
heat loss Nursing care
6th ed. P645
-importance of
Taylor Et.Al
contacting a
Nursing
health care
Diagnosis
provider when
Reference
problems
Manual 6th
related to temp
Ed. pp. 525-
 regulation 526

NURSING GOALS/EXPECTE NURSING

CUES/DATA RATIONALE RATIONALE EVALUATION
DIAGNOSIS D OUTCOMES INTERVENTION

     After 1 day of       After 1 day of

nursing intervention, nursing
Subjective: Imbalanced Nutritional the neonate will intervention, the
nutrition: problem arise receive adequate goal is partially
N/A less than with the fluid and nutrients met, as
Objective: body preterm infant for growth during evidenced by:
requirement because the hospitalization:
 Absent s related to body is 1. established
sucking ineffective attempting to an effective
reflex suck reflex continue to suck and
 Birth weight: swallow
maintain the INDEPENDENT:
2.3 kgs reflexes,
 Current rapid rate of 1. establish allowing for
Weight: 2.0 intrauterine effective suck Assess the To help
adequate
kgs growth. and swallow neonates sucking eliminate nutritional
 Ideal body Therefore, the reflexes, pattern. Try to ongoing intake
weight: 2.2 – preterm allowing for correct ineffective difficulties
4 kgs adequate sucking pattern
newborn
 Stool nutritional
characteristic requires a intake Make sure the
s: loose, larger amount To enable the
neonate’s tongue is
brown with of nutrients in neonate to suck
properly positioned
tinge of
 green in color a diet than the under the nipple of adequately
 Type of mature infant the mother
feeding: does.
discontinuati
Nutritional
on of OGT,
breastfed. problems are
 Poor muscle compounded
tone by the preterm Monitor the neonate
2. maintain for signs of To establish the 2. maintained
 pale infant’s
good skin need for good skin
conjunctivae immature dehydration, such
turgor, moist immediate turgor,
 Pale mucous reflexes, as poor skin turgor,
mucous moist
membrane dry mucous medical
which makes membrane mucous
and flat , soft membranes, intervention membrane
swallowing
and sucking fontanels increase or and flat ,
concentrated urine, soft
difficult.
fontanels
& sunken fontanels
and eyeballs.
(Maternal & Assess the need for
Child health The neonate
gavage feeding
Nursing, 4th may temporary
Ed. By require an
Pillitteri, alternative
p.739) means of
obtaining
adequate fluid
and calories
 CUES/ DATA NURSING RATIONALE GOALS/ NURSING RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTIONS
Subjective: Risk for The anatomic After 2 hours INDEPENDENT: After 2 hours
aspiration and functional of nursing (1) elevate head (1) semi of nursing
-N/a since a related to immaturity of interventions, of bed or place fowler’s interventions,
potential diagnosis premature the infant will child in semi relaxes the infant did
preterm tension of the
infant’s not Fowler’s position, not
Objective: impaired infants elevate experience or position head abdominal experienced
- 34 2/7 sucking their risks for aspiration of the baby muscles, aspiration
weeks of reflex minor and upright allowing for
gestation more - the infant will improved - the infant
- Immature significant maintain clear breathing maintained
gag reflex complications, breath sounds (2)to allow
clear breath
- Absence of (2) observe for sounds
like aspiration the infant to
sucking signs to stop
in which entry feeding rest
reflex
- With OGT of secretions, momentarily,
- RR: 52 solids, or such as elevated
breaths per fluids into the eyebrows,
minute trachea wrinkled forehead
passages is
(3) burp
high. All (3) infants are
frequently
newborns particularly
because of
have poor subject to
excessive air
accumulation
muscle tone swallowing
of the cardiac of gas in the
sphincter of stomach
the while feeding,
and this can
esophagus,
cause
thus causing considerable
regurgitation. agitation to
Newborn’s (4) hold an infant the child
cough reflex is with his head unless it is
not well elevated during burped
developed. feeding and
position her in an (4)such
Moreover,
infant seat after positioning
during the first feeding uses gravity
few days of to prevent
life, the regurgitation
newborn has of stomach
increased (5)instruct the contents and
mucus. family members promotes
in the home care lung
plan expansion

Source: (5) the child

Ladewig et al. and the
Contemporary family
members
Maternal- must
Newborn demonstrate
Nursing care the ability to
6th ed. P 653 ensure
adequate
home care
before
 discharge

Source:
Nursing
Diagnosis
Reference
Manual 6th
edition by
Ralph and
Taylor pp.
394- 395

CUES/DATA NURSING RATIONALE GOALS and NURSING RATIONALE EVLUATION

DIAGNOSIS OBJECTIVES INTERVENTIONS
Subjective: Risk for injury Phototherapy After 8 hours INDEPENDENT: After 8 hours
related to use exposes the of nursing (1)Cover baby’s (1)Protects of nursing
n/a since it of newborn to high interventions eyes with eye retina from interventions,
is a phototherapy intensity light. the neonate patches while damage due to the goal is
potential light Because it is not will be free of under high intensity fully met.
diagnosis known if injury phototherapy light. Neonate was
phototherapy Infant did not lights. free of injury.
Objective: injures the have corneal (2) Make certain (2)Prevents The infant’s
delicate structure irritation or that eyelids are corneal eyes are
-10 days old of the eye, drainage, skin closed prior to abrasions. protected,
-temperature: particularly the breakdown, or applying eye skin is intact,
36.2ºC retina, it is major patches. and
-jaundiced important to use fluctuation in (3) Remove baby (3) Provides maintained a
skin eye patch over temperature. from under visual stable
- patient is in the closed phototherapy and stimulation and temperature.
photo therapy newborn’s eyes. remove eye facilitates
for 4 days Skin breakdown patches during attachment
- on breast- and fluctuation of feeding. behaviors.
milk, OGT temperature is (4) Inspect eyes (4)Prevents or
feeding also possible each shift for facilitates
-consumes considering that conjunctivitis, prompt
five the infant has drainage and treatment of
diapers/day delayed growth corneal abrasions purulent
-labs: and development due to irritation conjunctivitis.
increased and ineffective from eye patches.
bilibrubin thermoregulation (5) Administer (5) Frequent
levels . thorough perianal defecating
cleansing with increases risk of
Source: Ladewig each stool. skin breakdown.
et al. (6) Provide (6) Provides
Contemporary minimal coverage maximal
Maternal- – only of diaper exposure,
Newborn Nursing area. shielded areas
care 6th ed. become more
P758 jaundices, so
maximum
exposure is
essential.
(7) Avoid use of (7) Prevents
oily applications superficial burns
on the skin. on skin.
(8) Reposition (8) Provides
baby every 2 equal exposure
hours. of all skin areas
and prevents
pressure areas.
(9) Observe for (9) Bronzing is
bronzing of skin. related to use of
phototherapy
with increased
direct bilirubin
 levels or liver
damage; may
last for 2-4
months.
(10) Place (10)Hypothermia
plexiglas shield and
between baby hyperthermia
and light. Monitor are common
baby’s skin and complications of
core temperature phototherapy.
frequently until Hypothermia
tmperature is results from
stable. exposure to
lights,
subsequent
radiation, and
convection
losses.
(11) Check (11) Hyethermia
axillary may result from
temperature. the increased
environmental
heat.Additional
heat from
phototherapy
lights frequently
causes rise in
baby’s
temperature.
Fluctuations in
temperature
may occur
inresponse to
 radiation and
convection.

CUES/ DATA NURSING RATIONALE GOALS/ NURSING RATIONALE EVALUATION

DIAGNOSI OBJECTIVES INTERVENTION
S S
Subjective: Risk for The After 8 hours of INDEPENDENT: After 8 hours of
infection r/t newborn’s nursing (1) ensure that (1) handwashing nursing
-n/a since a spread of immune interventions the all people prevents the interventions,
potential pathogens infant will not coming in spread of the goal is fully
system is not
diagnosis secondary experience contact with pathogens met. The infant
to identified fully spread of infant wash their coming from the did not
Objective: sepsis and activated infection as hands well infant to the experienced
immature until some manifested by before & after caregiver and spread of
- patient is immune time after - Infant’s touching the vice versa infection as
diagnose system birth. HR baby (2) this would manifested by
d with Limitation in remains prevent the - Infant’s
neonatal <160 (2) ensure that spread of HR
the
sepsis bpm all equipment pathogens to the remained
upon newborn’s used for infant is infant from <160
- RR is
admissio inflammatory <60 sterile, equipment bpm
n response cycles/ scrupulously - RR was
- -RR; 58 result in min clean & <60
 cycles/mi failure to disposable. Do cycles/
n recognize, not share min
- HR: 148 localize, and equipment with
bpm other infants
destroy
- Labs: (3) placing the
invasive (3) place infant in infant in an
Increased
WBC levels bacteria thus, isolette/ isolation isolette allows
increasing room per hospital close observation
risk for policy of the ill neonate
infection. & protects other
infants from
infection
(4) a neutral
(4) maintain thermal
neutral thermal environment
environment decreases the
metabolic needs
Source: of the infant. The
Ladewig et ill neonate has
al. difficulty
Contemporar maintaining a
y Maternal- stable temp.
Newborn (5) assessments
(5) assess TPR provide
Nursing care & BP, auscultate information about
6th ed. P. 580 breath sounds the spread of
infection,
increased RR and
HR, decreased
BP are signs of
sepsis. Spread of
infection may
cause resp.
 distress
(6) resp. support
(6) provide may be needed
respiratory during the acute
support phase of the
(oxyhood) infection to
prevent additional
physiological
stress
(7)nutritional
needs may
(7) feed infant as increase during
ordered (OGT) infection while the
infant may feed
poorly. OG
feedings ensure
that nutrient
needs are met if
the infant is too ill
to suck effectively
(8) lab results
provide
(8) monitor lab information about
results as the pathogen and
obtained. Notify infant’s response
care giver of to illness and
abnormal treatment
findings (9) assessments
coagulationprovid
e information
(9) monitor infant about the
for development of
hypoglycemia, complications of
jaundice, infection:
development of hypoglycemia,
thrush, or signs hyperbilirubenia,
of bleeding opportunistic
infections, and
coagulation
deficits
(10) IV
DEPENDENT: fluidsnhelp
maintain fluid
(10) administer balance
IV fluids as (11) antibiotics
ordered act to inhibit the
(D10IMB) growth of bacteria
(11) administer and destruction of
antibiotics as bacteria.
ordered Delmar’s
Maternal- Infant
Nursing Care
Plans 2nd edition
by Karla Luxner
p. 237
 Cues Nursing Rationale Goals and Interventions Rationale Evaluation
Diagnosis Objectives

After 8 hours of After 8

nursing hours of
Objective: Risk for The newborn intervention nursing
Impaired skin lies in one intervention,
 Patient is integrity related position for a
on goal is fully
to exposure to long period of met.
photothera 1. Patient’s skin
py for 4 high intensity time that may Patient’s
light result in skin will remain
days skin
secondary to breakdown. intact
 Consumes remained
5 diapers phototherapy Due to lack of intact as
per day adipose INDEPENDENT: evidenced
 Slightly tissue, the
jaundice in by:
pressure
color  No signs of
exerted by  No signs
 Dry skin skin  Change  Patient
 Patient in bony breakdown position every position changes of skin
supine prominences 2 hours will allow exposure breakdow
position on the skin is of the phototherapy n
 Has no lights to all areas of
greater thus
clothes on the body that are
increases the uncovered.
during
photothera risk of skin Pressure areas
py, only breakdown. may develop if
mittens, newborn lies in one
socks, and position for an
diapers extended period of
Source: time.
 Has eye
cover Ladewig et al.
during Contemporary
phototherapy Maternal-  Patient may
Newborn  Monitor develop a
Nursing care skin for rashes maculopapular rash
and bronzing which is transient
6th ed. P763
every 8 hours. side effect of
phototherapy

 Inspect
perianal area  Newborns
after each under phototherapy
diaper change lights have
for signs of increased loose
breakdown green acidic stools
which can be
irritating to the skin.
The diaper area
should be
thoroughly cleaned
after each soiled
 diaper to prevent
skin breakdown.
 Avoid
using lotions or
ointments on  Lotions and
the newborn’s ointments may
skin cause skin to burn
if applied to
exposed areas
during
phototherapy.
Source: Ladewig et al.
Contemporary Maternal-
Newborn Nursing care
6th ed. P759- 761

Diagnosis Plan/Goal Outcome Criteria Interventions Rationale Evaluation

Dx: Ineffective Plan: to monitor 1. Infant’s body 1.Monitor axillary
thermoregulation newborn closely to temperature will
related to immature maintain temperature remain within normal
axillary range, 36.5-
temperature control and prevent
37 degrees Celsius
and decreased hyperthermia and cold (Glass, 1999, p. 188).
subcutaneous body fat. stress
2.Provide heat/warm
2. Mother will verbalize
possible methods of
Goals: heat loss &
demonstrate
understanding of
conduction,
Long-term: Newborn
convection,
will be able to sustain 3.Maintain thermal
radiation, &
adequate/normal self evaporation within
thermoregulation. 12 hours.
3. Mother will
Short-term: Provide demonstrate
assistance and support maintenance of a
to maintain neutral thermal
adequate/normal environment within
24 hours.
temperature
4. Mother will
demonstrate proper
skin-to-skin warming
technique prior t
discharge.
1.Regular temperature 1. Newborn self
temperature at least monitoring will maintains adequate
every 8 hours; more identify adequate or body temperature for
frequently for infants inadequate 24 hours prior to
at high risk. thermoregulation discharge.
(Glass, 1999, p.188).
Axillary temperature
is good indicator of 2. Mother
the newborn using newborn’s surface demonstrates
incubators, radiant temperature (Glass, effective
warmer, swaddling, maintenance of
1999, p. 188).
and skin-to-skin neutral thermal
contact. environment within
2.To warm the 24 hours.
newborn and
adequately maintain
neutral environment accepted thermal 3. Mother verbalizes
and avoid situations range (Wong, 2003, methods of possible
that might p. 371). heat loss within 12
predispose the infant hours.
to heat loss, such as
cool air, drafts, 3.To maintain stable
bathing, and cold body temperature of 4. Mother
bedding. the newborn and demonstrates proper
decrease the skin-to skin warming
possibility of heat technique prior to
loss through discharge.
conduction,
convection,
radiation, &
evaporation (Wong,
2003, p. 371).