Notre Dame University

COLLEGE OF HEALTH SCIENCES

Cotabato City

NURSING CARE PLAN

Patient’s Name: Baby Girl Age/Sex: 0 y.o. /Female
Cc: Diagnosis: Preterm birth

HRP Nsg Dx AMB (S/Sx) Pathophysiological Client Nursing Intervention Rationale Evaluation
Basis Outcome
Safety/ Risk for Thermal equilibrium After 8hours of
Protection hypothermia r/t  T= 36.3C is affected by nursing 1. Monitor VS every 1.
ineffective ● BW=2.4 kg relative humidity, air intervention, hour 2. To promote
thermoregulati ● APGAR= flow, direct contact the client will be 2. Keep baby dry and warming of the
on secondary 5,7 with cool surfaces, free of out of cool body and to avoid
to prematurity ● Cold skin proximity to cool complications environment and moisture which
as manifested objects, and ambient related to wear appropriate promotes
by low body air temperature. neonatal warm clothing to the evaporative heat
temperature Neonates are prone hypothermia child loss
and body to rapid heat loss and maintain 3. Maintain a warm 3. To prevent
weight and consequent normal body ambient temperature drop
hypothermia temperature environment 4. A well-informed
because of a high within normal 4. Teach mother mother knows how
surface area to limits indications of to handle the
volume ratio, which hypothermia situation if ever
is even higher in problems arise
low-birth-weight
neonates. There are
several mechanisms
for heat loss:
 Radiant heat
loss: Bare
skin is
exposed to an
environment
containing
objects of
cooler
temperature.
 Evaporative
heat loss:
Neonates are
wet with
amniotic fluid.
 Conductive
heat loss:
Neonates are
placed in
 contact with a
cool surface
or object.
 Convective
heat loss: A
flow of cooler
ambient air
carries heat
away from the
neonate.