CUES/ DATA NURSING RATIONALE GOALS/ NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTIONS

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) development the inadequate initiate and as manifested by
- With Oxygen 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/EXPECTED NURSING
CUES/DATA RATIONALE RATIONALE EVALUATION
DIAGNOSIS OUTCOMES INTERVENTION

         After 1 hour of
intervention, the
Subjective:  Ineffective The preterm  After 1 hour of goal is fully met.
thermoregulation newborn has nursing intervention, The neonate
N/A related to a great deal patient will maintain maintained a
Objective: immaturity and of difficulty normal body stable body
lack of attaining body temperature from temperature at
 Gestational subcutaneous temperature 36.5-37.5 36 .7C
age of 34 and brown fat because she
weeks 2/7 INDEPENDENT: evidenced by:
has a
 Current
weight: 2.0 relatively 1. Staff members  Monitor the  To 1. staff
kgs large surface will take steps neonate’s determine members
 Neurological area per to maintain body the need kept
status: neonate’s temperature for neonate’s
kilogram of
LOC: body until discharge interventio body
body weight. temperature
Lethargic temperature at n and the
In addition, at normal
 Capillary refill normal level. effectivene
because the Pt. will have a ss of level.
time of 3
seconds. infant does and warm, dry therapy. neonate has
 Integumentary not flex the skin warm, dry
Status: body well but skin
 Dry  Drying
 pale legs, remains in an newborn quickly and
Moderate extended thoroughly and placing and
pallor position. quickly and placing on a
 cool and dry
Rapid cooling discard the wet warm, dry
skin
from blanket. Place surface
 Turgor: less
evaporation is the infant under prevent heat
than 3 a pre warmed loss from
seconds likely to
radiant warmer.
 neonate is occur. evaporation.
placed in the
isolation room The preterm  Avoid  Cold
 Temperature: infant has placing infant surface and
35.5 C little on cold surface instrument
 Mild shivering subcutaneous or using cold increase
 Baby is instrument in heat loss by
fat for
placed in an assessment. conduction
extended insulation and
position poor
 Poor muscle muscular  To
tone development  Ambient prevent
 Labs: does not temperature of excessive
 Increased the room where cooling.
allow the
Hemoglobin the newborn is
child to move kept should be
(198 g/l)
 increased actively as monitored
Hematocrit the older
(0.58 g/l) infant does to  Helps
 increased promote heat.  Mummify conserve
WBC (10.3 x and use thick heat in the
The preterm
10 d/l) blankets to body
infant also cover the
has limited 2. parents will patient 2. parents
amount of express  Teach the  The expressed
brown fat; understanding mother about infant’s head understandin
of neonate’s the infant’s provides a g of
special tissue
thermoregulat need for large surface neonate’s
present in ory thermoregul
warmth and to area for heat
newborns to disturbance atory
keep the loss
maintain body and disturbance
infant’s head
temperature. thermoregulati covered and
on thermoregul
ation
Source:  Teach family  Careful
Maternal and members teaching
Child Health about: allows
-signs and family
Nursing, 4th
symptoms of members
Ed. By to take an
altered body
Pillitteri, active role
temperature,
p.741 in
such as cool maintaining
extremities. the
neonate’s
- factors in health.
home that
contribute to
neonatal heat Sources:
loss and ways Ladewig et al.
to minimize Contemporary
heat loss Maternal-
Newborn
-importance of Nursing care
contacting a 6th ed. P645
health care Taylor Et.Al
provider when Nursing
problems Diagnosis
related to temp Reference
regulation Manual 6th
Ed. pp. 525-
526
 NURSING GOALS/EXPECTED NURSING
CUES/DATA RATIONALE RATIONALE EVALUATION
DIAGNOSIS 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:
requirements because the hospitalization:
 Absent 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 a diet than the adequately
under the nipple of
green in color mature infant
 Type of the mother
does.
feeding:
Nutritional
discontinuati
on of OGT, problems are
 breastfed. compounded
 Poor muscle by the preterm
tone infant’s 2. maintain Monitor the neonate To establish the 2. maintained
 pale good skin for signs of need for good skin
immature turgor, moist turgor,
conjunctivae dehydration, such immediate
 Pale mucous reflexes, mucous moist
which makes as poor skin turgor, medical
membrane membrane mucous
swallowing and flat , soft dry mucous intervention membrane
and sucking fontanels membranes, and flat ,
difficult. increase or soft
concentrated urine, fontanels
& sunken fontanels
and eyeballs.
(Maternal &
Child health Assess the need for The neonate
Nursing, 4th gavage feeding 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 premature the infant will child in semi relaxes the infant did
preterm infants tension of the
diagnosis infant’s not experience Fowler’s position, not
impaired elevate their aspiration or position head abdominal experienced
Objective: sucking reflex risks for minor of the baby muscles, aspiration
- 34 2/7 and more - the infant will upright allowing for
weeks of significant maintain clear improved - the infant
gestation complications, breath sounds breathing maintained
- Immature like aspiration clear breath
gag (2) observe for (2)to allow the sounds
in which entry infant to rest
reflex signs to stop
of secretions, feeding
- Absence
of solids, or fluids momentarily,
sucking into the such as elevated
reflex trachea eyebrows,
- With passages is wrinkled forehead
OGT high. All (3) infants are
- RR: 52 (3) burp
newborns particularly
breaths frequently
have poor subject to
per because of
muscle tone of accumulation
minute excessive air
of gas in the
the cardiac swallowing
stomach while
sphincter of feeding, and
the this can cause
esophagus, considerable
thus causing agitation to the
regurgitation. child unless it
Newborn’s is burped
cough reflex is
not well (4) hold an infant (4)such
with his head positioning
developed.
elevated during uses gravity to
Moreover, feeding and prevent
during the first position her in an regurgitation
few days of infant seat after of stomach
life, the feeding contents and
newborn has promotes lung
increased expansion
mucus.
(5)instruct the (5) the child
family members and the family
in the home care members
Source: plan must
Ladewig et al. demonstrate
the ability to
Contemporary
ensure
Maternal- adequate
Newborn home care
Nursing care before
6th ed. P 653 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/ NURSING RATIONALE GOALS/ NURSING RATIONALE EVALUATION
DATA DIAGNOSIS OBJECTIVES INTERVENTIONS
Subjective: Risk for The After 8 hours of INDEPENDENT: After 8 hours of
infection r/t newborn’s nursing (1) ensure that all (1) handwashing nursing
-n/a since a spread of immune interventions the people coming in prevents the interventions,
potential pathogens infant will not contact with infant spread of the goal is fully
system is not
diagnosis secondary experience wash their hands pathogens coming met. The infant
to identified fully activated spread of well before & after from the infant to did not
Objective: sepsis and until some infection as touching the baby the caregiver and experienced
immature time after manifested by vice versa spread of
- patient immune birth. - Infant’s (2) ensure that all (2) this would infection as
is system Limitation in HR equipment used prevent the spread manifested by
diagno the newborn’s remains for infant is of pathogens to - Infant’s
sed <160 sterile, the infant from HR
inflammatory
with bpm scrupulously equipment remained
neona response clean & <160
- RR is
tal result in <60 disposable. Do bpm
sepsis failure to cycles/ not share - RR was
upon recognize, min equipment with <60
admis localize, and other infants cycles/
sion destroy min
- -RR; (3) place infant in (3) placing the
invasive
58 isolette/ isolation infant in an isolette
bacteria thus, room per hospital allows close
cycles
/min increasing policy observation of the
- HR: risk for ill neonate &
148 infection. protects other
bpm infants from
- Labs: infection
Increased (4) maintain (4) a neutral
WBC neutral thermal thermal
levels environment environment
decreases the
Source: metabolic needs of
Ladewig et al. the infant. The ill
Contemporary neonate has
Maternal- difficulty
maintaining a
Newborn
stable temp.
Nursing care (5) assess TPR & (5) assessments
6th ed. P. 580 BP, auscultate provide
breath sounds information about
the spread of
infection,
increased RR and
HR, decreased BP
are signs of
sepsis. Spread of
infection may
cause resp.
distress
(6) provide (6) resp. support
respiratory may be needed
support (oxyhood) during the acute
phase of the
infection to
prevent additional
physiological
stress
(7) feed infant as (7)nutritional
ordered (OGT) needs may
increase during
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) monitor lab (8) lab results
results as provide
obtained. Notify information about
care giver of the pathogen and
abnormal findings infant’s response
to illness and
treatment
(9) monitor infant (9) assessments
for hypoglycemia, coagulationprovid
jaundice, e information
development of about the
thrush, or signs of development of
bleeding complications of
infection:
hypoglycemia,
hyperbilirubenia,
opportunistic
DEPENDENT: infections, and
coagulation
(10) administer IV deficits
fluids as ordered (10) IV fluidsnhelp
(D10IMB) maintain fluid
(11) administer balance
antibiotics as (11) antibiotics act
ordered to inhibit the
growth of bacteria
and destruction of
bacteria.
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.
phototherap 1. Patient’s skin
y for 4 days high intensity time that may
will remain Patient’s
 Consumes light result in skin skin
secondary to breakdown. intact
5 diapers remained
per day phototherapy Due to lack of intact as
 Slightly adipose INDEPENDENT: evidenced
jaundice in tissue, the
color by:
pressure
 Dry skin  No signs of
exerted by  No signs
 Patient in skin  Change  Patient
bony of skin
supine breakdown position every position changes
prominences breakdow
position 2 hours will allow exposure
on the skin is n
 Has no of the phototherapy
clothes on greater thus lights to all areas of
during increases the the body that are
phototherap risk of skin uncovered.
y, only Pressure areas
breakdown.
mittens, may develop if
socks, and newborn lies in one
diapers position for an
 Has eye Source: extended period of
cover Ladewig et al. time.
during Contemporary
phototherapy
Maternal-
Newborn  Patient may
Nursing care develop a
6th ed. P763  Monitor maculopapular rash
skin for rashes which is transient
and bronzing side effect of
every 8 hours. phototherapy

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