Newborn Nursing Diagnosis

[Daytonite, BSN, RN]

As bortazintx has told you, "baby always wrapped in a blanket, temperature monitored every ? Hours" are nursing interventions and not evidence (proof) that you have temperature fluctuation between hypothermia and hyperthermia (the definition of this diagnosis).

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

One aim (goal) of interventions is to maintain the environmental temperature between 89.6f to 92.3 f (Foundations of Maternal-Newborn Nursing, by Sharon Murray, Emily McKinney, Karen Holub, and Renee Jones) so that the newborn does not develop an increased need for oxygen, an increased metabolic rate and maintains a normal blood sugar. This PDF details hypothermia in the newborn and the interventions...

Thermal Protection of the Newborn: A Practical Guide - (excerpts below)

2.2 Causes and risk factors

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Hypothermia of the newborn is due more to lack of knowledge than to lack of equipment. Incorrect care of the baby at birth is the most important factor influencing the occurrence of hypothermia.

In many hospitals, delivery rooms are not warm enough and the newborn is often left wet and uncovered after delivery until the placenta is delivered. The newborn is weighed naked and washed soon after birth. The initiation of breast-feeding is frequently delayed for many hours, and the baby is kept in a nursery, apart from the mother. Separation of the mother and baby makes it more difficult to keep the newborn warm; it also increases the risk of hospital-acquired infections and has an adverse effect on breast-feeding and bonding.

2.4 Management of hypothermia

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Newborns found to be hypothermic must be rewarmed as soon as possible. The temperature of the room where the rewarming takes place should be at least 25°c (77°f). Cold clothes should first be removed and replaced with pre-warmed clothes and a cap. The newborn should be quickly rewarmed; if a warming device is used, the baby should be clothed and its temperature should be checked frequently during the rewarming process. It is very important to continue feeding the baby to provide calories and fluid. Breast-feeding should resume as soon as possible. If the infant is too weak to breast-feed, breast milk can be given by nasogastric tube, spoon or cup. It is important to be aware that hypothermia can be a sign of infection.

Every hypothermic newborn should therefore be assessed for infection.

In hospital a diagnosis of hypothermia is confirmed by measuring the actual body temperature with a low-reading thermometer, if available. The method used for rewarming depends on the severity of the hypothermia and the availability of staff and equipment.

In cases of mild hypothermia (body temperature 36.0-36.4°c/96.8-97.5°f), the baby can be rewarmed by skin-to-skin contact, in a warm room (at least 25°c/77°f).

In cases of moderate hypothermia (body temperature 32-35.9°c/89.6-96.6°f) the clothed baby may be rewarmed:

• Under a radiant heater;
• In an incubator, at 35-36°c (95-96.8°f);
• By using a heated water-filled mattress;
• In a warm room: the temperature of the room should be 32-34°c/89.6-93.2°f (more if the baby is small or sick);
• In a warm cot: if it is heated with a hot water bottle or hot stone, these should be removed before the baby is put in;
• If nothing is available or if the baby is clinically stable, skin-to-skin contact with the mother can be used in a warm room (at least 25°c/77°f).

The rewarming process should be continued until the baby's temperature reaches the normal range. The temperature should be checked every hour, and the temperature of the device being used or the room adjusted accordingly. The baby should continue to be fed.

In cases of severe hypothermia (body temperature below 32°c/89.6°f), studies suggest that fast rewarming over a few hours is preferable to slow rewarming over several days.29,30,31 rapid rewarming can be achieved by using a thermostatically-controlled heated mattress set at 37-38°c (98.6-100.4°f) or an air-heated incubator, with the air temperature set at 35-36°c (95-96.8°f). If no equipment is available, skin-to-skin contact or a warm room or cot can be used.

Feeding should continue, to provide calories and fluid and to prevent a drop in the blood glucose level which is a common problem in hypothermic infants. If this is not possible, monitoring blood glucose becomes important and an intravenous line should be set up to administer glucose if needed.

Once the baby's temperature reaches 34°c (93.2°f), the rewarming process should be slowed down to avoid overheating. The temperature of the incubator and the baby's body temperature should be checked every hour.

At home, skin-to-skin contact is the best method to rewarm a baby with mild hypothermia. For best effect, the room should be warm (at least 25°c/77°f), the baby should be covered with a warm blanket and be wearing a pre-warmed cap. The rewarming process should be continued until the baby's temperature reaches the normal range or the baby's feet are no longer cold. The mother should continue breast-feeding as normal.

Hot water bottles or hot stones can be dangerous: they may easily cause burns as the blood circulation in the cold skin of babies is poor. They should therefore never be put next to the baby. If used to warm a cot, they should be removed before the baby is put in.

If the baby becomes lethargic and refuses to suckle, these are danger signs and it should be taken to hospital. While being transported, the baby should be in skin-to-skin contact with the mother during transportation, otherwise one of the methods listed in section 4.8 can be used.

[Daytonite, BSN, RN]

Risk for infection related to immature immunologic response and extrauterine exposure as evidence by strict handwashing/sanitizing orders by caregiver before handling the baby.

This is an anticipated problem (a problem that doesn't exist yet). Therefore, it cannot have any evidence because it does not exist yet. So, "strict handwashing/sanitizing orders by caregiver before handling the baby" first of all, and again as with your ineffective thermoregulation diagnosis, does not fit the definition of evidence supporting the existence of the problem of an infection. These are interventions. Secondly, "risk for" diagnostic statements, unlike the diagnostic statements of actual nursing problems, only consist of 2 parts:

• The nursing diagnosis
• The risk factor

So, if you want to say that this baby has

• Risk for infection (Nursing diagnosis)
• Related to immature immunologic response and extrauterine exposure (The risk factors)

Then there can be no aeb evidence since there is no infection-- yet. The goal of your nursing interventions will always be to prevent the problem from occurring with these "risk for" diagnoses.

To accomplish that you need to know what infection or place of infection that you are focusing on. It happens to be the umbilical cord stump in this case. You also need to know what the signs and symptoms of infection of the cord stump are. otherwise, how will you know if an infection does show up? If signs and symptoms of an infection occur, you no long have a risk of infection, but some other problem that you must then assess and diagnosis.

So, start again. . .

Diagnosis: Risk for infection related to immature immunologic response and extrauterine exposure.

Here are weblinks to information on umbilical cord care and the signs of infection of the umbilical cord stump which were found using the links from

From Umbilical cord care: Do's and don'ts for parents ...

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During the healing process, it's normal to see a little crust or dried blood near the stump. Contact your baby's doctor if your baby develops a fever or if the umbilical area:

• Umbilical cord infections are uncommon. But if your baby has an infection, prompt treatment can stop the infection from spreading.
  • Appears red and swollen around the cord
  • Continues to bleed
  • Oozes yellowish pus
  • Produces a foul-smelling discharge

Care of the cord includes:

• Keep the stump clean
• Keep the stump dry
• Do sponge baths rather than bathe the baby in the tub or the sin
• Let the cord fall off on its own

Another good one - Umbilical Cord Cutting and Care for Newborns

One more point before I go, when you sequence these diagnoses, make sure you list the ineffective thermoregulation first since it is an actual problem and the risk for infection next since it is only an anticipated problem:

1. Ineffective thermoregulation r/t immature compensation for changes in the environmental temperature aeb ???
2. Risk for infection related to immature immunologic response and extrauterine exposure

[Bortaz, MSN, RN]

Your AEBs are more interventions than support facts that justify the diagnosis, in my opinion. AEB axillary temp of *, for instance, shows that the baby indeed has poor thermoregulation.

[liltam7]

Thank you so much for your reply!

Another diagnosis for my newborn is...

Risk for infection related to immature immunologic response and extrauterine exposure as evidence by strict handwashing/sanitizing orders by caregiver before handling the baby

I need evidences and its hrd if baby doesn't have infection, this is only risk for...

Interventions will be wash hands before handling the baby

Monitor temperature

Assess umbilical cord...

Any other interventions? or helpful websites would help too... thanks!