Name: Vina Marie G.

Derit
Section: BSN 2-01

Nursing Care Plan

Patient’s initial: B.G.Q.S.

Cues Nursing Rationale Goal and Nursing Rationale Evaluation

Subjective Risk for A preterm infant has Goal: The Independent: Goal met
Cues: ineffective little subcutaneous newborn’s
thermoregulation fat for insulation and temperature is ● Encourage ● To enhance Short term
N/A related to the poor muscular thermoregulated the mother parental After 1 hour of
immaturity of development and so at 97.6°F to have bonding while nursing
newborn. cannot move as (36.5°C) axillary. proving interventions:
skin-to-skin
Objective actively as an older warmth to the
Cues: infant to produce Short term contact with newborn and 1. The patient
body heat. They also Within 1 hour of the newborn to give the was able to
T- 35°C have a limited intervention: and teach mother the minimize
amount of brown fat, proper knowledge on further body
Wt- 2.3 kg the special tissue 1. The patient swaddling what she heat loss.
Bl- 42 cm present in newborns will be able to should do to 2. The patient
HC- 32 cm that helps maintain minimize body keep the maintained a
AC- 29 cm body temperature. heat loss. newborn warm and
CC- 25 cm Preterm infants also warm and comfortable
cannot shiver, a 2. The patient prevent heat environment.
useful mechanism to will be able to loss.
increase body maintain a warm
temperature, nor can environment by
they sweat and manipulating the ● Provide ● To stimulate Long term
thereby reduce body environmental immediate breathing and After discharge:
temperature because stimuli. and restore the
of their immature normal 1. The mother
thorough
central nervous Long term temperature. was able to
system and After discharge: drying after properly
hypothalamic control. delivery of demonstrate
(Pillitteri, 2017) 1. The mother the baby. maintaining
demonstrates the newborn’s
proper handling ● Monitor ● To determine temperature
of the newborn’s temperature if the patient’s within the
temperature temperature normal value.
every 1-2
such as proper is improving. 2. The family
swaddling, hours. was able to
postponing early verbalize the
bathing, etc. ● Wrap the ● To reduce importance of
newborn heat loss from skin-to-skin
2. The family with a dry the head and contact and
verbalizes the cloth and the maintain reporting of
importance of overall early signs of
newborn's
skin-to-skin warmth. hypothermia.
contact and head with a 3. The patient’s
signs of early bonnet. temperature
hypothermia. was able to
● Use of cling ● To modify improve and
3. The patient wrap to the environmental is within the
will manifest a stimuli and normal range.
bassinet for
temperature reduce heat
within the normal the newborn loss.
range
(36.5°C-37.5°C)
● Instruct the ● To prevent
mother to heat loss.
postpone
bathing until
 at least 6
hours.

● To provide
● Teach the
immediate
patient’s
care and
family of the
prevent
early signs
further
of
complications.
hypothermia
such as skin
cold, pale,
prolonged
crying,
tachypnea,
etc.

Dependent:
● Administer
● To prevent
Neonatalyte
metabolic
containing
acidosis.
4% sodium
bicarbonate
as
prescribed.

Collaborative:
● Refer to the
● To prevent
nutritionist
other
for the
complications
newborn’s
such as loss
proper diet
of fluids.
care.
 References

Balest, A. L. (n.d.). Hypothermia in Neonates - Pediatrics - MSD Manual Professional Edition. MSD Manuals. Retrieved March 13,

2022, from https://www.msdmanuals.com/professional/pediatrics/perinatal-problems/hypothermia-in-neonates

CMNRP. (n.d.). Newborn Thermoregulation. Retrieved March 13, 2022, from

http://www.cmnrp.ca/uploads/documents/Newborn_Thermoregulation_SLM_2013_06.pdf

Flagg, J. A. S. (2018). Nursing Care of a Family with a High Risk Newborn. In A. Pillitteri (Ed.), Maternal and Child Health Nursing:
Care of the Childbearing & Childbearing Family (8th ed., pp. 1504–1505). essay, Wolters Kluwer

Hypothermia NCLEX Review Care Plans. (n.d.). NurseStudy.Net. Retrieved March 13, 2022, from

https://nursestudy.net/hypothermia-nursing-care-plans/

Newborn Care: 7. Temperature control and hypothermia. (n.d.). Bettercare. Retrieved March 13, 2022, from

https://bettercare.co.za/learn/newborn-care/text/07.html#hypothermia