Nursing care plan

Of The newborn
 Nursing Care Plan of the newborn
Cues/Evidence Nursing Diagnosis Objective Intervention Rationale Evaluation

OBJECTIVE DATA: Ineffective breathing Within our Assess and report Further signs and At the end of our
Dx: NSVD with thick pattern r/t aspiration care, the further sings of symptoms could care, the newborn
meconium stain of meconium during newborn will respiratory distress lead to achieved effective
birth have an complications breathing pattern
Presence of thick effective which may result as evidenced by;
(dark) meconium breathing to chronic hypoxia
during suctioning (in pattern as and acidosis, RR= 58 cpm fast
nose and mouth) evidenced by; increasing the risk and shallow
of CNS damage
Use of mechanical Absence of Clear the newborns Flaring of the ala
suctioning respiratory airway by suctioning This helps remove nasi not observed
distress such the mouth using a bulb accumulated fluid, anymore
Slight flaring ala nasi as flaring of syringe facilitates
during the P. A of the ala nasi, respiratory effort nose and mouth
newborn cyanosis, and helps prevent were free of mucus
dyspnea and further aspiration secretions
Sneezing noted during abnormal
initial care breath sound Note the pitch and Initially, a strong good cry was
intensity of the cry of cry increases initiated
RR= 63 cpm RR should be the newborn alveolar pressure
within normal of oxygen and
Newborn has faint range produces the
cries (30 –60cpm) necessary
chemical changes
Absence of to convert fetal to
 mucus neonatal
secretions in circulation, so that
the nose and the heart rate
mouth increase to 175-
180uterus
Initiation of
good cry

OBJECTIVE DATA: Risk for infection r/t Within our Monitor vital signs Determine any At the end of our
Dx: NSVD with thick immature immune care, the abnormal changes, care, the newborn;
meconium staining system newborn will; raise in
temperature may Vital signs
Presence of thick Vital signs indicate infection remained within
(dark) meconium within normal normal range
during suctioning (in range Allows recognition Temp.= 37˚C
nose and mouth) T= 34 o C of abnormal HR= 139 bpm
PR= 120 – findings and allow RR= 58cpm
Vital signs: 160 bpm prompt
RR= 30 –60 intervention if Newborn is free of
Temp.= 36.8˚C
cpm washing hands before complication signs and
HR= 125bpm and after providing occurs symptoms of
Manifest no care infection such as
RR= 63cpm
signs of Hand washing is fever and fatigue
infection like the single best
fever and way to avoid Mother had fully
chills wearing gloves to spreading understood the
maintain asepsis when pathogen importance of
providing direct care breastfeeding in
and when in contact Gloves reduce the relation to
with blood or body possibility of strengthening the
secretions transmitting immunity
disease
Monitor WBC count
above 11,000/mm3

Indicates
increased
production of
leukocytes by
bone marrow,
Encourage mother to usually in
begin breastfeeding response to the
early if indicated presence of
bacterial
pathogens

Colostrum and
breast milk
Instilling eye ointment contain high
(gentamicin ointment) amounts of
immunoglobulin A,
which provides
passive immunity
and helps reduce
infection

Instill ophthalmic
drops or ointment
to provide
prophalaxis
against opthalmia
menatorum