Neonate care plan

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    Hi! I don't know if everyone's care plan format is the same but on ours at the top we have to list a medial dx, surgical dx, and admitting dx. I am STRUGGLING to come up with these three for a newborn. Any suggestions??
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    All of those are found in the chart. As a nurse you do not make medical diagnoses, so you don't come up with them. You originate nursing diagnoses from the defining characteristics listed in the NANDA-I 2012, 2014, which if you don't have, you had better get (free 2-day shipping for students from Amazon).

    Look under the admitting physician's/pediatrician's note for the admitting diagnosis and the medical (not medial) diagnosis. Surgical diagnosis is found only if the patient had surgery, and you will find a brief post-operative note on the day of surgery and a day or two later a complete dictated and typed operative report.

    If you are looking at a normal newborn, your admission and medical diagnoses are going to look something like "Normal newborn, (date of birth), X weeks gestation, to G# P# A#" where that means the mother's history of # of gravida (pregnancy), para (deliveries), and abortions (or other lost pregnancies). You would find this in the admitting sheet from the nursery.

    If the baby has had no surgery, then you don't have a surgical diagnosis, and you put, "none."
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    I meant medical. Ha!
    I thought it was weird to ask for surgical dx, etc. We haven't been able to look at the chart & our instructor wanted us to "try" to correctly fill those out. I don't see how it is possible.
    Thanks for your help!
  6. 0
    unless the baby's had in utero surgery or has been circumcised
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    Quote from hbrooks4
    Hi! I don't know if everyone's care plan format is the same but on ours at the top we have to list a medial dx, surgical dx, and admitting dx. I am STRUGGLING to come up with these three for a newborn. Any suggestions??
    You will only have a surgical diagnosis if the baby had surgery. Most babies in the newborn nursery have not because, if they require surgery they are typically transferred to a NICU or a pediatric hospital. Or, as Esme points out, if a baby boy was circumcised you list that. If the baby has not had surgery, there is no surgical diagnosis.

    Admitting and medical diagnoses could be any number of things depending on what's going on with that baby. "Normal newborn", "preterm infant", "macrosomia", "hypothermia", "hyperbilirubinemia", etc. What is going on with YOUR baby? Did the baby experience any hypothermia and have to be put under the warming lights? Did they have jaundice and have to go under the bili lights? Are they eating well? What was their birth weight? Is their newborn exam normal?


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