The only information I have is: newborn 03/01/12; 6#10oz, Apgar 6 and 7; breast-fed with poor latch on; sleepy; spitting up; voided/stooled twice; Temp: 96; HR 120; RR 42; Ballard scale gestation: 38 weeks; Normal NB
I am struggling with these. I have a big lecture test Monday, but I cannot study for it from worrying about these. I have to turn them in before the test. I have to do a care plan on each one consisting of: Assessment Data, Nursing Diagnosis, Goal/Expected Outcome (with A.E.B), and then Plan of Care with rationales.
I have to do 3 physiological, 1 safety/security, and 1 knowledge deficit. Then, I have to make a list of 10 possible ND for this newborn and put them in priority order.
I have the following:
Risk for ineffective airway clearance r/t inability to clear mucus by cough and expectoration (immature lungs?)
Risk for fluid volume deficit r/t immature age and neonatal transition (?)
? - I need another one - Do you have any suggestions?
(1) safety/security (Would this be Safety/Security because of skin or Phys. cause of circulation?
ineffective thermoregulation r/t immature compensation to the environmental temperature
(1) Knowledge Deficit
deficient knowledge of car seats r/t lack of experience and lack of exposure to infant car seats (?)
I have written out my care plans for the the four above (probably not very well). If someone could please help me come up with one more diagnosis with a r/t statement, I would appreciate it. I do not want someone to do it for me, just need a little boost. I either need a safety and security or a physiological; I am not sure which one this is: ineffective thermoregulation r/t immature compensation to the environmental temperature. We were taught according to Maslow's that circulation is physiological, but skin is safety/security. Does anyone know? Thank you so much