What would be a good Nursing Diagnosis for my Maternity Care Plan?

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So I have to do a nursing care plan (a.k.a., Nursing Process Report/NPR). And I'm still rather unsure how this spiel works out.

I was on a newborn nursery unit on Tuesday, and I picked out a newborn baby to look at the charting and do my assessment on. But the baby was pretty much normal and A-OK, so I don't even know if I'd have nursing diagnoses that I could do a care plan on.

(For my class's care plan, by the way, I just have to pick 1 Nursing Diagnosis and do the care plan on that.)

Anyhoo, I scoured through my data sheet, and the baby DID have a blood glucose test run because he was 9 lbs. 3 ozs., and I think that the hospital's policy is to automatically run a glucose test if the baby's bigger than 9 lbs. The baby's blood glucose was 49, which was one below the minimum 50. Hypoglycemia, eh?

So I figured I'd find a nursing diagnosis on that.

I have a maternity-specific care plans book with me. It's called "Maternal Newborn Nursing Care Plans" (2nd ed.) by Carol J. Green. I'm scouring through it to find an appropriate diagnosis for this baby, but I can't find any.

There's this one Nursing Diagnosis that says "Risk for Impaired Gas Exchange", and right underneath it says "Related Factors: meconium aspiration, polycythemia, hypothermia, and hypoglycemia".

Oooh! I thought. It says "Hypoglycemia".

So should I write "Risk for Impaired Gas Exchange r/t hypoglycemia" as my nursing dx?

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Just my opinion, but I wouldn't use that. I mean is the baby having gas exchange issues? The baby checked out ok and didn't need RT? If not than you are creating something that doesn't exist. My understanding of newborns with low glucose is that the change from being fed by mom and now baby being fed directly sometimes this will happen after the birthing process (energy used) and when baby will get next feeding (especially being larger and having higher metabolic nees than a smaller baby). So I think it needs to have something to do with nutrition and body requirements imbalance...that is what is causing the problem that we already know is there. The impaired gas exchange can be a result of the low glucose after prolonged time without treatment they can present with periods of apnea and can become cyanotic in late stages.

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That's what's making this so hard. Other than that low blood glucose reading, I seriously can't find anything wrong with this baby. But I need to do a care plan! Grrr

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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

Think about what is important to watch for in a newborn. The biggies with newborns are temperature (which you rightly picked) 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. One other thing to keep an eye on is jaundice from hyperbilirubinemia.

So think (risk) thermo-regulation R/T immature thermo-regulation for environment, imbalanced nutrition R/T (actual) poor feeding, thermo-regulation, diabetic Mom AEB hypoglycemia

https://allnurses.com/nursing-student-assistance/help-newborn-careplan-290606.html

https://allnurses.com/nursing-student-assistance/newborn-nursing-diagnosis-760113.html

Do you see where I'm going?

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

From another member Daytonite (RIP)

Critical Thinking Flow Sheet for Nursing Students

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Like I said, the baby's doing just fine. I saw the baby with the mother, and the bonding was perfectly fine. The baby *was* slightly macrosomic, obviously due to the weight, and was born at 40.5 weeks. Mom's 38 by the way. I couldn't use "Ineffective thermoregulation" because I've got zero evidence for this nursing diagnosis anyway. Other than that low blood glucose, everything is WNL. In fact, I'm not even sure if a nursing intervention would BE warranted because everything's just fine. Why intervene when there's no risks or problems?

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Specializes in Cardiology, Cardiothoracic Surgical.

Another few I can think of are:

risk for impaired maternal-child bonding if mom's gotta worry about her diabetes as well

risk for ineffective tissue perfusion (going back to the cold stress)

risk for aspiration (was this baby post term? was the amniotic fluid meconium stained?)

knowledge deficit r/t newborn care (look at other aspects of the mother- how well does she understand how to do the

simple things like bathing, feeding. etc.)

Also look at psychosocial factors- is there an intact family structure? Does the mother speak English? Does she have access to

health care and financially be able to take care of the newborn? Does she have a supportive partner? These will all

affect the newborn's development as well.

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But the mom doesn't have a diagnosis of diabetes (I looked in her chart). I couldn't find any of the psychosocial stuff in the chart (the binder's THIS THICK!), but I didn't see anything in the chart that would indicate that the baby's mom was doing poorly. And the whole ineffective tissue perfusion-slash-cold stress is moot because obviously the newborn's in a warmer. I didn't even have the maternity care plan book until after I got out of my clinicals, so it's not like I could retrospectively go back and try to fish out a nursing diagnosis-related problem from the mother.

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Oh, check this out!

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Why don't I just say "Risk for Birth Trauma secondary to Macrosomia"? I looked in the index and it's the ONLY thing I could find for macrosomia.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Like I said, the baby's doing just fine. I saw the baby with the mother, and the bonding was perfectly fine. The baby *was* slightly macrosomic, obviously due to the weight, and was born at 40.5 weeks. Mom's 38 by the way. I couldn't use "Ineffective thermoregulation" because I've got zero evidence for this nursing diagnosis anyway. Other than that low blood glucose, everything is WNL. In fact, I'm not even sure if a nursing intervention would BE warranted because everything's just fine. Why intervene when there's no risks or problems?

You are falling into the same hole that trips most new students. You find your diagnosis and then try to retrofit the patient into the diagnosis. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

Could the babies low glucose be due to ineffective thermoregulation (one of the signs of ineffective thermoregulation)? All babies are at risk for thermoregulation issues.....it's because they are new born. A big concern for all babies is to keep them warm and don't let them overheat. Since this baby is macrosomic (slightly by weight)....what is one of the symptoms of macrosomia?

Let the information you have drive the diagnosis....you have a big newborn with a low glucose. Is this a male baby? what about circumcision? Is the baby breast fed? What about the umbilical site?

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

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

How about .........

low glucose/hypoglycemia R/T ineffective thermoregulation/macrosomia/gestational age AEB glucose of 49, birth weight of 9lbs and gestational age of 40.5.

Use the information you have. The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

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. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly. I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition

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. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.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: ADPIE

  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)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Then the risk for is what you should be looking for that could possibly go wrong. Was the baby a vag delivery? Is this the first pregnancy/birth? What is the Mom's situation at home.

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Wait wait, so would it be "Risk for ineffective thermoregulation r/t low blood glucose" or "Risk for ineffective thermoregulation AEB low blood glucose"?

I'm not sure what the technical difference between "related to" and "as evidenced by" is. In other words, when do you use which one?

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