CLIENT CARE PLAN Student Name: Clients Initials: KS Tiese Lopez Date: 03/08/2011 Ericksons Developmental Stage Maternal:

Ericksons Developmental Stage Newborn: Infancy

IMPLEMENTATION EVALUATION

ASSESSMENT/NURSING DX.

OUTCOME IDENTIFICATION/PLANNING

Nursing Diagnosis: Risk for Body Temperature Alteration Related to: Inability to shiver change in environment from interuterine to extrauterine, and limited amount of insulation. Subjective data: Mother asked Will my baby be warm in just a blanket?

Client-Centered Outcome with Indicators: Infant will remain free of complications that precipitate Hypothermia and cold throughout his stay in the hospital A.E.B: Vitals within normal range 1. T-96.8-99F 2. P-120-160 3. RR-30-60 Absence of respiratory distress Absence of hyperbilirubinemia

Therapeutic Nursing Interventions: Encourage mother to hold baby for skin to skin contact. If mother is not available place infant under radiant warmer at 37c for 2-4hrs. Keep baby dry and wrapped in a blanket; keep the infants head covered with a cap.

Scientific Rationale for each Intervention: Ways to stabilize the newborns body temperature include placing the infant directly on the mothers abdomen (shannon E. Perry, 2010, p. 648). Body temperature maintenance-drying and wrapping the newborn in warmed blankets immediately after birth, and keeping the head well covered (shannon E. Perry, 2010, p. 648). Cold stress increases the need for O2 and may deplete glucose stores. The infant may react to exposure to cold by

Implementation:

Evaluation of Outcome:

Place baby on mothers abdomen for skin to skin contact for 1-2hrs.

Goal met AEB maintained stable body temperature of 98.0 F by the end of my shift, no signs of respiratory distress, infants color is pink, and skin is warm to the touch.

Objective data: Term birth (37.6 weeks) Color Pink Respirations unlabored Chart data: Spontaneous Labor No signs of distress in infant Mother was given an Epidural Vitals T-98.0

Teach mother how to swaddle baby to keep him warm when not held by her or the father. Keep cap on infants head.

Observe for signs of cold distress by observing color, temp, and respirations.

Take temperature every hour until temperature is stable. Assess baby every 1-2 hrs.

Revisions: No revisions need to be made.

P-148 RR-64

increasing respiratory rate and may become cyanotic. Body temperature should be taken every hour until temperature is regulated (shannon E. Perry, 2010, p. 648).

DATA supports the nursing diagnosis

OUTCOME must be related to nursing diagnosis. Outcome statement: who, what, conditions, when, how Indicators are: -realistic/measurable -attainable within time available -related to client data and stated outcome

THERAPEUTIC INTERVENTIONS are based on identified outcome with: -action to be performed -descriptive phase-time/how often -congruent with other therapies

SCIENTIFIC RATIONALE -documented from published source with APA -reflects understanding of intervention -reflects client data

IMPLEMENTATION Identify what was actually done for each therapeutic nursing intervention Identify which interventions were not implemented

EVALUATION to determine if each outcome was met: completely, partially, not at all States revisions planned based on evaluation of indicators

References:

shannon E. Perry, M. J. (2010). Maternal Child Nursing Care. Maryland Heights: Mosby Elsevier.