Newborn Nursing Diagnosis

Nursing Students Student Assist


I am a second year nursing student and am stuck on 4 nursing diagnosis for my patient. He is a 3 week old and I was only able to be with him for approximately 15 minutes to do an assessment. His vitals were WNL for his age, his only problem was he was diagnosed with Herpes Simplex Virus yesterday. I would appreciate any help/suggestions for diagnosis that I can use for this patient.

Specializes in L&D.

What do you know about HSV and the outcome for an infant?

Unfortunately I know nothing and I think that is why I am having so much trouble. I don't learn that content until next semester and I believe that is why I don't know what nanda diagnosis to use. I know that they will have to be geared toward the mother and the only one I can think of is "knowledge deficit r/t transmission of hsv aeb infant testing positive"

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

What is a newborn at risk for? Even a healthy infant. How is the infant feeding? Are 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? Is mom understanding what the diagnosis is indicative of? What learning does mom need to care properly for baby? Is this her first 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
  • what does the hsv diagnosis mean for the baby? (this is where google and doing your detective work will be required)neonatal herpes simplex - symptoms, tests, treatment
Active herpes simplex virus is associated with spontaneous abortion in the first trimester of pregnancy and an increased risk of preterm labor after 20 weeks’ gestation. If a patient has active herpes around the time of the estimated date of delivery, cesarean section is the preferred method of delivery. Infected infants can develop the following signs and symptoms after an incubation period of 2 to 12 days: fever, hypothermia, jaundice, seizures, poor feeding, and vesicular skin lesions.

So what would you have to look for in the infant with these symptoms? Does the baby have lesions? Where are they? What does mom need to know? Does she need to know how to care for the lesions? What information does she need to know about the meds for baby? What does mom need to ab aware of? Is mom treated for her hsv? Why is a baby with an infection a potential dangerous situation? Can an infant have the immune system strong enough to fight the infection without becoming critically ill and developing hsv encephalitis?

Who | standards for maternal and neonatal care

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)

  1. 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)
  2. 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)
  3. Planning (write measurable goals/outcomes and nursing interventions)
  4. Implementation (initiate the care plan)
  5. 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 its rns 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. Diabetic moms have kids who are used to insulin bringing the blood sugar down. After birth, that insulin keeps on pumping for a little while and can send blood sugar plummeting.

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 febrile fluid balance is disturbed. How many wet diaper 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

Infection r/t hsv infection aeb........

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

I hope this helps.

Thank you for all of your time and guidance. This is wonderful information and will greatly assist me in my nursing care plans

Fyi: "We aren't supposed to learn that until next semester" is probably not a good thing to think or say to an instructor:d. Part of your assignment is to learn things on your own.

So consider going to the library and finding articles or a book on nicu nursing or perinatal nursing that addresses a baby with herpes. Tell the librarian what you need and ask her to show you how to use the cumulative index of nursing and allied health literature (cinahl)-- the library probably has an online access contract-- to locate it. A few good nursing mag articles should really be helpful here.

This is my first time using this, I unfortunately didn't know these were instructors that were answering my questions but thankfully they were very helpful in assisting me with the way I should think about this assignment. I am unfortunately stuck in a pediatric clinical while learning about geriatric and med surg in lecture. It is hard to find time with a full time job, 2 children, and being in full time summer classes to learn a lot of outside material and have already tried other resources with minimal help. That is why I found this site in hopes of some additional help which I have received. Thank you for your advice.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

We are happy to help. Google is also your friend. Many students just don't know how to start or start in the wrong place. Technically, I am not an instructor although I have been an educator in hospitals. I have issues with clinicals that are not con-current because it is difficult to assimilate the information. There is also a search box on the upper right hand side of the page type in what you want there and you will also get results.

We really are happy to help.

I used to teach in nursing school but now feed my teaching habit on AN. We won't do anyone's homework for her even if she has a chaotic or demanding home life (about which we can all sympathize, truly) but share the philosophy that it's best for students to learn how to find info for themselves-- the old teach-a-man-to-fish thing. Hope these resources have been helpful in getting you there.Welcome to the profession!

Ineffective thermoregulation

Risk for injury

Knowledge deficit, newborn care

Risk for SIDS

Risk for infection

It would help if you knew a few more things. Is it a first time mom? GBS positive? lady partsl delivery?

I have an assignment to figure out a newborn wellness diagnosis. I'm wondering if I can include assessment data from the parents, as the baby can't vocalize any intent to improve. I chose Readiness For Enhanced Nutrition based on the following data... the defining characteristics are from Carpenito, and I added the correlating assessment data:

  • Expresses willingness to enhance nutrition - Baby shows rooting and sucking reflex, drinks formula from bottle
  • Eats regularly - Documented successful feedings (formula)
  • Consumes adequate food and fluid - appropriate wet/dirty diapers, weight loss less than 10%
  • Follows an appropriate standard for intake - Parents verbalize the need to feed baby every 3-4 hours (formula)
  • Safe preparation and storage for food and fluids - Parents demonstrate knowledge to discard prepared formula after one hour.

Does this make sense or am I totally off base??

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

YOu are on the right track........but newborns (other than my own) is not my forte. 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. Are they treating this cord stump? If it's inflamed or there are 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 has been circumcised that is another reason for a risk of infection.

Is this baby breastfeeding? if so, use effective breastfeeding. 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 if the baby is under the bili light for hyperbilirubinemia the nursing diagnosis to use is risk for injury r/t phototherapy.

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