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, the effective about experienced an
- Preterm birth and delayed 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 relatively 1. staff
weight: 2.0 1. Staff members  Monitor the  To
large surface will take steps neonate’s determine members
kgs kept
 Neurological area per to maintain body the need
neonate’s temperature for neonate’s
status: kilogram of
body until discharge interventio body
 LOC: body weight. temperature
temperature at n and the
Lethargic In addition, at normal
normal level. effectivene
 Capillary refill because the ss of level.
Pt. will have a
time of 3 infant does therapy. neonate has
and warm, dry
seconds. not flex the warm, dry
skin
 Integumentary body well but skin
Status: • Dry newborn • Drying
 pale legs,
remains in an
thoroughly quickly
Moderate extended and quickly and
pallor position. and discard placing
 cool and dry Rapid cooling the wet and
skin from blanket. placing on
 Turgor: less evaporation is Place the a warm,
than 3 infant under a dry
likely to
 seconds occur. pre warmed surface
 neonate is radiant prevent
placed in the The preterm warmer. heat loss
isolation room infant has from
 Temperature: little evaporatio
35.5 C subcutaneous • Avoid placing n.
 Mild shivering infant on cold
fat for
 Baby is surface or • Cold
insulation and using cold
placed in an surface
poor instrument in and
extended
position muscular assessment. instrument
 Poor muscle development increase
tone does not heat loss
 Labs: allow the by
• Ambient conduction
 Increased child to move
temperature
Hemoglobin actively as of the room
(198 g/l) the older where the • To prevent
 increased infant does to newborn is excessive
Hematocrit kept should
promote heat. cooling.
(0.58 g/l) be monitored
The preterm
 increased
WBC (10.3 x infant also
10 d/l) has limited 2. parents will 2. parents
• Mummify and
amount of express expressed
use thick • Helps
brown fat; understanding understandin
blankets to conserve
of neonate’s g of
special tissue cover the heat in the
thermoregulat neonate’s
present in patient body
ory thermoregul
newborns to disturbance • Teach the atory
maintain body and mother about disturbance
the infant’s • The
temperature. thermoregulati and
need for infant’s
on thermoregul
warmth and head
ation
 to keep the provides a
infant’s head large
Source: covered surface
Maternal and area for
Child Health heat loss
Nursing, 4th
Ed. By  Teach family
Pillitteri, members
p.741 about:
-signs and
symptoms of  Careful
altered body teaching
allows
temperature, family
such as cool members
extremities. to take an
active role
- factors in in
home that maintaining
contribute to the
neonatal heat neonate’s
loss and ways health.
to minimize
heat loss Sources:
Ladewig et al.
-importance of
Contemporar
contacting a
y Maternal-
health care
Newborn
provider when
Nursing care
problems
6th ed. P645
related to temp
Taylor Et.Al
regulation Nursing
Diagnosis
Reference
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:
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,
rapid rate of 1. establish allowing for
 Current Assess the To help
Weight: 2.0 intrauterine effective suck adequate
growth. and swallow neonates sucking eliminate nutritional
kgs
 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
requires a intake
characteristic Make sure the
larger amount To enable the
s: loose, 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
the mother
 Type of does.
feeding: Nutritional
discontinuati problems are
on of OGT,
compounded
breastfed.
by the preterm Monitor the neonate 2. maintained
 Poor muscle 2. maintain To establish the
tone infant’s good skin for signs of good skin
need for
 pale immature turgor, moist dehydration, such turgor,
immediate moist
conjunctivae reflexes, mucous as poor skin turgor,
membrane medical mucous
 Pale mucous which makes dry mucous
membrane and flat , soft intervention membrane
swallowing membranes,
fontanels and flat ,
and sucking increase or soft
difficult. concentrated urine, fontanels
& sunken fontanels
and eyeballs.
 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
- Immatur like aspiration clear breath
e gag (2) observe for (2)to allow the sounds
in which entry infant to rest
reflex signs to stop
- Absence of secretions, feeding
of solids, or fluids momentarily, such
sucking into the 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
agitation to the
thus causing
child unless it
regurgitation. is burped
Newborn’s
cough reflex is (4) hold an infant (4)such
not well with his head positioning
developed. elevated during uses gravity to
Moreover, feeding and prevent
position her in an regurgitation
during the first
infant seat after of stomach
few days of feeding contents and
life, the promotes lung
newborn has expansion
increased
mucus. (5)instruct the (5) the child
family members and the family
in the home care members
plan must
Source: demonstrate
Ladewig et al. the ability to
Contemporary ensure
Maternal- adequate
home care
Newborn before
Nursing care discharge
6th ed. P 653
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
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 - RR is clean & <160
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
cycles bacteria thus, room per hospital allows close
/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
metabolic needs
Source: of the infant. The
Ladewig et al. ill neonate has
Contemporar difficulty
y Maternal- maintaining a
Newborn stable temp.
Nursing care (5) assess TPR & (5) assessments
BP, auscultate provide
6th ed. P. 580
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 goal is fully
on
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
intact
• Consumes secondary to breakdown. 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 position
bony of skin
• Patient in breakdown position changes will
prominences breakdo
supine every 2 allow exposure of
on the skin is wn
position hours the phototherapy
• Has no greater thus lights to all areas
clothes on increases the of the body that
during risk of skin are uncovered.
photothera breakdown. Pressure areas
py, only may develop if
mittens, newborn lies in
socks, and one position for
diapers Source: an extended
• Has eye Ladewig et al. period of time.
cover Contemporary
during Maternal- • Patient may
phototherap develop a
Newborn
y maculopapular
Nursing care • Monitor skin rash which is
6th ed. P763 for rashes transient side
and effect of
bronzing phototherapy
every 8
hours.
• Newborns under
phototherapy
• Inspect lights have
perianal increased loose
area after green acidic
each diaper stools which can
change for be irritating to the
signs of skin. The diaper
breakdown area should be
thoroughly
cleaned after
each soiled
diaper to prevent
skin breakdown.

• Avoid using • Lotions and

lotions or ointments may
ointments cause skin to
on the burn if applied to
newborn’s exposed areas
skin during
phototherapy.
Source: Ladewig et al.
Contemporary Maternal-
Newborn Nursing care
6th ed. P759- 761