ST. ANTHONY COLLEGE CALAPAN CITY, INC.

Bayanan I, Calapan City

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
OBJECTIVE: •Risk for After 30 - Remove the - To provide - After 30
Temperature: decreased minutes of umbilical cord oxygen minutes of
36.1°C oxygenation nursing that wrapped deprivation nursing
Cardiac rate: 179 related to intervention the from the and to intervention the
bpm nuchal cord baby's vital baby’s neck prevent baby’s vital signs
Respiratory signs and decreased in and oxygen
Rate: 84cpm oxygen heart rate saturation
Oxygen saturation will remain within
saturation: 97% remain within normal limits.
normal limits.

- To reduce
- Provide an heat loss
immediate from
drying of the evaporation,
patient after dry the baby
birth. right after
birth with a
dry towel or
cloth.
ST. ANTHONY COLLEGE CALAPAN CITY, INC.

Bayanan I, Calapan City

- Obtained vital - To
signs determine
especially the the vital sign
temperature are with in
normal
range

- This is
important to
ensure that
- Monitor the the baby is
baby’s vital stable and
signs and getting
oxygen enough
saturation. oxygen.

- promote the
- Encourage the
baby’s
parents to hold
ST. ANTHONY COLLEGE CALAPAN CITY, INC.

Bayanan I, Calapan City

and cuddle the comfort and

baby, and relaxation to
provide help reduce
opportunities stress and
for skin-to-skin improve the
contact to baby’s
promote overall well-
relaxation and being.
bonding. Encouraging
the parents
to hold and
cuddle the
baby, and
providing
opportunities
for skin-to-
skin contact,
can help
foster a
bond
between the
baby and the
parents and
promote
relaxation.