Nursing Care Plans for Newborn

  1. I am a new poster to this website, but I have been reading it for awhile. I posted this on another topic, then I saw this one for Nursing Student Assistance (where I should have posted it). I am going to do better next time.

    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 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 my work 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
    Last edit by Joe V on May 22, '18
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    About Adelene

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


  3. by   nurseprnRN
    nursing diagnoses come from nursing assessments, the same way that medical diagnoses come from medical assessments. you don't just pick a medical diagnosis and then start writing down nursing diagnoses.

    nursing diagnoses are derived from nursing assessments, not medical ones (although some we use the same data for our diagnoses). so to make a nursing diagnosis, a nursing assessment has to occur. for that, well, you need to either examine the patient yourself, or (if you're planning care ahead of time before you've seen the patient) find out about the usual presentation and usual nursing care for a given patient.

    medical diagnoses, when accurate, can be supporting documentation for a nursing diagnosis, for example, "activity intolerance related to (because the patient has) congestive heart failure/duchenne's muscular dystrophy/chronic pulmonary insufficiency/amputation with leg prosthesis." however, your faculty will then ask you how you know. this is the dread (and often misunderstood) "as evidenced by."

    in the case of activity intolerance, how have you been able to make that diagnosis? you will likely have observed something like, "chest pain during physical activity/inability to walk >25 feet due to fatigue/inability to complete am care without frequent rest periods/shortness of breath at rest with desaturation to spo2 85% with turning in bed."
    i hope this is helpful to you who are just starting out in this wonderful profession. it's got a great body of knowledge waiting out there to help you do well for and by your patients, and you do need to understand its processes.

    it looks like your faculty is asking you for evidence that your goal has been achieved. in the case of activity intolerance, above, your goals might be that the "patient says s/he is less exhausted" due to your interventions (which would probably be...?). you can tell the patient is less exhausted by the activity s/he has to do because "s/he says so /has a lower pulse and respiration rate/ doesn't desaturate so much."

    in the case of this baby, you're not going to get a lot of subjective data (that's a joke...babies aren't going to speak to you), so all your evidence is going to be objective things like temp, hr, rr, feeding ability, urine and fecal output, crying, color. i'd say look at the baby's ability to regulate body temp (how good is that in a newborn?) and what would you assess, do, and evaluate for that? does that help?

    your beginning text says circulation is physiological, and that's true. skin could be safety, because broken skin is usually the result of an unsafe thing (even surgery is just expensive trauma:d); imo skin could also, in some circumstances, be seen in a physiological light, as in looking at its ability to regulate fluids & temperature.
  4. by   Adelene
    Thank you for your response. I need all the help I can get to understand these wonderful nursing diagnoses.

    I decided to use “risk for imbalanced Nutrition: less than body requirements r/t insufficient intake.”

    The mother is having problems feeding her baby. It has poor latch on, it is sleepy, and it is spitting up.

    Also, the Apgar score of 6, 7 (can indicate a stressful birth – used more brown fat and maybe depleted glucose stores) and the low temp of 96F (cold stress will also need more glucose for body heat).

    Like you said, I have no “subjective data,” just the objective. LOL

    We were taught that skin is safety/security, but I agree with you. I think skin could be physiological. Of course, I am going to go with what my instructors teach me... make the grade, you know...
  5. by   rn/writer
    I work with newborns, and a couple of things jump out at me. You're on the right track with your concerns about temp and blood glucose.

    Take this out of such an abstract realm and think about what this baby might need. What would you be most concerned about. Which pieces from the data that you were given are most alarming? What other information might you like to have? How do the different bodily systems interact to possibly compound problems.

    Focus on what YOU can do for this child and then work backwards to the diagnoses.

    I'll check back in a half hour or so to see what you've come up with.
  6. by   Adelene
    In reality without all the fancy stuff, I would be taking the baby to the mother’s room and begging her to use skin-to-skin contact and breast feed her baby. I would stand by her side and help her if needed. If that did not work, I would beg her to let me try to feed the baby. I would put it in the incubator (trying to get the temperature regulated) and if I could not get it to feed from a bottle, I would use a dropper, a spoon or something… I am talking as a mother who has raised two children…

    I have a HUGE lecture test at 8:00 in the morning that I am cramming for (I know we aren’t supposed to do that), so I just wrote the best I could on the Nursing Diagnosis that I have to turn in at 7:55 in the morning.

    I would love to come back and get some advice on my next assignment. I do not want anyone to do my work for me, but it helps to get advice on how to do these diagnoses. Maybe something you say will help me learn it.

    Thank you for trying to help.
  7. by   rn/writer
    Your last post shows you''ve got a good head on your shoulders and some common sense, as well.

    In the real world, I would add getting a dexi (blood glucose) on the baby and a rectal temp if the 96 was axillary. Such a low temp burns through brown fat and blood glucose quickly. If the dexi was below 40, I'd order a stat serum glucose. Depending on that result, I might encourage mom to supplement right away. If the rectal temp was 96 or below, I might put the baby under a warmer. Then, when the temp had come up some, mom could help maintain it with skin-to-skin.

    Temp and blood glucose are the most serious issues going on with the kid you described above. At 38 weeks, the lungs are not immature, even if the airway is a little juicy. That isn't at all abnormal.

    We nurses can order stat serum glucose levels where I work. Not sure what the parameters are where you are doing your clinicals.

    I hope you do well on your exam and care plans tomorrow.
  8. by   Adelene
    Well, I made an 80 on the test! I passed the care plans, but I made some mistakes.

    How long does it take to get comfortable doing the care plans? I am struggling just to figure out if my assessment data belongs with a certain diagnosis. So far we have had pretend patients to do our care plans on, and we are never provided with enough data – not enough for me anyway.

    HIPPA laws are brutal... understandably; we cannot use real patient’s information after leaving a facility.

    Spring Break after Friday!! yeah!!
  9. by   Esme12
    good for you.....and it's hipaa not hippa. (pet peeve) you can use patients information, if permitted by your school, with no identifiers to the patient. pretend patients do make it difficult as your care plns should be based on assessment data and then conclude your nursing diagnosis based upon that data. check out these links....they will help you alot!! and get a good care plan book

    care plan basics:
    every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the nanda taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. you need to have access to these books when you are working on care plans. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is get this information to help you in writing care plans so you diagnose your patients correctly.

    don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. these will become their symptoms, or what nanda calls defining characteristics.

    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:
    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)
      Questions about writing good care plans.
    ok....first to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms. let me try to help you. there are many nurses here and many who came before me to this site but one nurse stands out.....daytonite(rip) can also use the search on this site to lead you to care plans. i have supplied links of examples at the bottom for care plans.

    the "related to" part of the nursing diagnostic statement is the etiology, cause, or what is contributing to the nursing diagnosis. "related to" things include cultural, environmental, physiological, psychological and developmental changes the patient is experiencing. nursing diagnosis handbooks can help you determine the wording you need to use for this section of your diagnostic statement. an explanation of the meaning of what follows the words "related to" can be found in the beginning chapter(s) of any nursing diagnosis handbook.
    CAREPLANS HELP PLEASE! (with the R\T and AEB)
    CAREPLANS HELP PLEASE! (with the R\T and AEB)