Need help with priority Nursing Dx for healthy neonate

[cmarcus]

All we were given to go off of for our nursing dx is it is a term newborn male from birth to 48 hours old. I need help finding 3 priority nursing diagnosis. I was thinking along the lines of inadequate thermoregulation r/t immaturity of neuroendocrine system, Risk for respiratory distress syndrome r/t inadequate surfactant and risk for hypoglycemia r/t cold stress. Thanks in advance for your help!

[Esme12, ASN, BSN, RN]

What semester are you? What care plan book are you using? This is a full term male....Is surfactant an issue? Vag delivery? What is a newborn at risk for? even a healthy infant. How is the infant feeding? re they latching on? Was this a vag birth? Was the baby full term? What about mom? How is she with the baby? Are they bonding? How does mom feel about the baby? How old is mom? What learning does mom need to care properly for baby? is this her first baby?

What is your assessment of Mom and Baby?

Thermoregulation in a newborn is a neurological system adaptation to extrauterine life. newborns lose body heat, and lose it rapidly, 4 ways because their neurological systems are not fully developed at birth:

• conduction (their warm body heat transfers to cooler objects that they come into direct contact with)
  
• evaporation from exposure of wet skin surfaces lost to the atmosphere
  
• convection (their body heats transfers to the air surrounding them)
  
• radiation (their warm body heat transfers to cooler objects around them)
  

ineffective thermoregulation in newborns is due to immature compensation (adaptation to) the environmental temperature. in other words, when the newborn encounters conduction, evaporation, convection and/or radiation when they come into this world, hypothermia occurs and they lose body heat and become hypothermic. once body heat is lost in a newborn, their immature system compensates by (here comes the pathophysiology of hypothermia, or ineffective thermoregulation in newborns):

• increasing their metabolism and increasing use of glucose and oxygen (to generate more heat)
  
• this causes their respiratory rate to increase leading to respiratory distress
  
• leads to hypoglycemia
  
• leads to metabolic acidosis
  
• leads to vasoconstriction (as the body attempts to retain heat)
  
• increasing cold leads to the production of fatty acids that interferes with bilirubin transport and can lead to jaundice
  

the biggest thing about a care plan is the assessment. the second is knowledge about the disease process........here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: from daytonite (rip)

• assessment (collect data from medical record, do a physical assessment of the patient, assess adls, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
  
• determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
  
• planning (write measurable goals/outcomes and nursing interventions)
  
• implementation (initiate the care plan)
  
• evaluation (determine if goals/outcomes have been met)
  

A care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. The nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. One of the main goals every nursing school wants the Students to learn by graduation is how to use the nursing process to solve patient problems.

Just like you need a recipe care to make a cake from scratch. A care plan is your recipe card to caring for your patient and what to look for while you are caring for them.

The biggies with all newborns are temperature and feeding. If there are problems with either of these (or baby has a diabetic mom), blood sugar will also be a concern. Low temp and inadequate intake can use up blood sugar as the body uses it for fuel.

Another thing to keep an eye on is jaundice from hyperbilirubinemia.....common in babies more common in sick babies that may not be feeding well. What about the umbilical cord site? What would you look for there? If the baby is not feeding well..... fluid balance is disturbed. How many wet diapers would baby need?

Risk for infection r/t break in skin integrity at umbilical cord site aeb..........

Ineffective thermoregulation r/t immature compensation for changes in environmental temperature

Imbalanced nutrition: less than body requirements r/t poor feeding behaviors

Risk for alteration in fluid/nutrition r/t .......aeb........

Risk for injury

Knowledge deficit, newborn care

Risk for SIDS

Risk for infection

I hope this helps.

[cmarcus]

I'm in my first semester of my junior year. The only book I have for nursing diagnosis is the Nursing Diagnosis Handbook by Ackley and Ladwig. It's not a real life infant and literally the only information we were given about the infant was that he was a full term male from birth to 48 hours. We know nothing about mother/baby relationship, nothing about the mother etc. This is only my second care plan and we have to have a full page of nursing diagnosis then narrow it down to 3 priority and then pick the top priority and write a care plan off that.

[Esme12, ASN, BSN, RN]

I use Ackley as well.......not a real patient and no information......

No wonder some students have so much trouble.....for the baby:

Think about what you know about the assessment findings of a normal newborn compared to an adult. What's different? For one thing newborns can't regulate their body temperature which is why we don't leave them exposed to the room atmosphere for very long with just a diaper covering them. that's ineffective thermoregulation r/t immature compensation for changes in environmental temperature. Some newborns just have a few difficulties with excessive secretions in the respiratory track (the big hint here is that the nurses will keep a bulb syringe nearby the baby) So ineffective airway clearance can be used. They also have a stump from the umbilical cord hanging off their future belly button.......umbilical cord problems there is risk for infection, so you can use risk for infection r/t break in skin integrity at umbilical cord site. If the baby is a male and has been circumcised that is another reason for a risk of infection and pain. Since breast feeding is being pushed these days......is this baby breastfeeding? If so, use effective breastfeeding. and, some babies just don't start feeding well at first by breast or bottle--it happens. These kids are imbalanced nutrition: less than body requirements r/t poor infant feeding behaviors.

[cmarcus]

Thank you! You definitely helped me narrow down the most important. Yeah it would definitely help if they gave us more information about the patient, but no such luck. Thanks again! I appreciate the help for sure!

[Esme12, ASN, BSN, RN]

we are happy to help....:) tell your fellow students!