Need help w/newborn care plan

[kashmir]

Hi I'm currently finishing a care plan for a healthy AGA newborn. I'm using the diagnosis:

Potential altered body temperature related to immature thermocontrol center, increased body surface: body weight ratio, and no insulation.

I for some strange reason cannot think of any possible objective signs for this! I have down that newborn is doubled wrapped in blanket and wearing a hat and gown. But my mind has drawn a blank! You'd think after doing these care plans for two years, I'd have a better idea. Anyone else have any ideas? I'd greatly appreciate it!

:plsebeg:

[Daytonite, BSN, RN]

you did say potential altered body temperature related to immature thermocontrol center, increased body surface: body weight ratio, and no insulation. meaning this to be an anticipated problem? this is usually an actual problem and the nursing diagnosis worded as:

ineffective thermoregulation r/t immaturity aeb inability to maintain body temperature within a steady normal range

another objective sign would be the record of temperatures being taken on a regular basis by the nursing staff. you need to have a nursing diagnosis reference to see the nanda information on the defining characteristics for this diagnosis. there are a number of ways to acquire this information.

• your instructors might have given it to you.
  
• you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
  
• many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  
• there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
  
  • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
    
  • http://www1.us.elsevierhealth.com/me...ctor/index.cfm
    

i already checked the two websites and neither one included a listing for this nursing diagnosis. these are the defining characteristics for this diagnosis (page 225, nanda-i nursing diagnoses: definitions & classification 2007-2008):

• cool skin
  
• cyanotic nail beds
  
• fluctuations in body temperature above and below normal range
  
• flushed skin
  
• hypertension
  
• increased respiratory rate
  
• mild shivering
  
• moderate pallor
  
• piloerection
  
• reduction in body temperature below normal range
  
• seizures
  
• slow capillary refill
  
• tachycardia
  
• warm to touch
  

[kashmir]

The nursing diagnosis used is one that the clinical instructor gave us to use. The diagnosis is off a list of one's she has chosen for us to use in this care plan. I am aware that it is not one in our NANDA approved nursing diagnosis handbook, however it's what she wants us to use, so I am. Thanks for the advice! :nuke:

[Daytonite, BSN, RN]

Then it sounds like an abticipated, not an actual problem. This means a problem that doesn't yet exist. You have to know the signs and symptoms of the problem. Your only nursing interventions can be to monitor for the signs and symptoms, do things to prevent the symptoms from occurring and report the symptoms when they do occur so management of them can be instituted immediately. I put a post about potential diagnoses on the Assistance - Help with Care Plans thread (https://allnurses.com/forums/f50/help-care-plans-286986.html) a few days ago.

[kashmir]

Thanks for your help! I figured it out