Newborn Nursing Diagnosis

  1. 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:

    3 physiological
    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
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    About Adelene

    Joined: Sep '11; Posts: 11; Likes: 2


  3. by   NicuGal
    For respiratory...look at the gestational age and what you wrote. Not immature, what age is considered premature or late premature? also,RR WNL, what are the norms for a newborn. Look at temp and think of thermoregulation. Is infant eating well? No, but again, look at your gest. age, baby is breastfeeding, think of what interventions you would have.

    Knowledge deficit...what is mom having a hard time with right not eating? Related to breastfeeding.
  4. by   Adelene
    Thank you so much for your reply.

    I forgot to mention - instructor specified that she wanted everyone to do Knowledge deficit about infant car seats - probably to teach ourselves. Very informative research - I could not believe that infant car seats have an expiration date! It makes sense; I just did not know about it. Think about all those old car seats at yard sales…

    I would love to do the breast feeding, but we were told not to do it. Probably because our textbook has an entire care plan laid out for ineffective breastfeeding r/t deficient knowledge of mother as evidenced by ongoing incorrect latch-on technique.

    Thank you for pointing out that less than 37 weeks is considered premature. I need to change my r/t statement. We also learned that normal vitals for a 2 day old newborn are:
    Respiratory rate ranges from 30 to 60 breaths/min

    Heart rate should be 100 to 160/min

    Blood pressure should be 60 to 90 mm Hg systolic and 40 to 50 mm Hg diastolic.

    Temperature should be 36.5 to 37.2 C (97.7 to 98.9 F) axillary.

    Given the above VS as norms, my NB has a low temp, but the rest is normal.

    We are just learning to do these care plans; I cannot wait for the light bulb to go off, and care plans become second nature to write!!