ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
S: Imbalanced SHORT-TERM; INDEPENDENT; SHORT-TERM;
Nutrition:
1. Assess the 1. This helps in
O: Less Than Within 8 hours of After 8 hours of
newborn’s identifying any
Body nursing nursing interventions
- Low birth ability to feed. feeding difficulties
Requirements interventions the the patient was able
weight or inadequate intake
related to patient will: to:
- Failure to early, allowing for
inadequate
thrive intake  Demonstrate prompt intervention.  Demonstrates
- Weak secondary to improved improved
suck/swallow ineffective feeding feeding
2. Provide Skin-to- 2. Skin-to-skin contact
reflex feeding behaviors. behaviors,
Skin contact promotes bonding,
- Decreased pattern as  Achieve including
during feeding. enhances
frequency and evidenced by adequate effective
breastfeeding
duration of low birth weight gain latching and
success, stimulates
breastfeeding weight and and sustained
milk production,
or bottle poor feeding hydration. feeding
and regulates the
feeding. behaviors. sessions
neonate's body
- Signs of LONG TERM;  Achieves
temperature and
dehydration Within 2 days of appropriate
breathing patterns.
(e.g., dry nursing 3. Monitor the weight gain
mucous interventions the and hydration
membranes, patient’s parent will status.
baby’s weight, 3. To make sure that
decreased demonstrate
growth, and the weight is
urine output). understanding of LONG TERM;
development. appropriate and
feeding techniques After 2 days of
4. Monitor the prevent weight loss,
and cues for hunger nursing interventions
newborn’s
and satiety. the patient’s parent
4. Dehydration can
hydration and
was able to
further affect
overall health
demonstrate
newborn nutrition
status.
confidence in feeding
and overall well-
techniques and
being. Monitor the
ability to recognize
newborn’s
cues for hunger and
fontanelles, skin
satiety.
turgor, mucous
membranes, and
Goal was Met.
5. Encourage urine and stool
mother to output.
choose 5. To assist mother in
nutritious foods finding healthy
such as options and have the
vegetables, neonate increase
fruits, and low- intake of nutritious
fat foods. feeding,
DEPENDENT;

6. Assess home
care for a clean
and quiet 6. To enhance comfort
environment. and minimize
disturbances that the
neonate may be
7. Educate mother
distracted from
how to express
lactating.
and store breast
7. Expressed breast
milk if
milk through
breastfeeding is
pumping can still
not possible.
provide infants with
the nutrients and
antibodies of breast
milk if
breastfeeding is
8. Instruct the
difficult.
mother on
8. Correct positioning
breastfeeding
helps the neonate
positions and
achieve a better
 latch, swallow
latching.
effectively, and
reduce the risk of
aspiration, ensuring
optimal feeding and
nutrition.
Collaborative:

9. Refer the
9. Lactation
mother and
consultants are
neonate to a
specialized
lactation
professionals who
consultant for
can provide tailored
expert
support and
assessment and
assistance to
guidance on
improve
breastfeeding
breastfeeding
techniques,
outcomes and
latch issues, and
address any
milk transfer.
breastfeeding-
related challenges.
10. Occupational
10. Instruct mother
therapists can
 provide specialized
to engage with
interventions, such
occupational
as oral stimulation
therapist to
techniques and
assess and
feeding therapy, to
address any oral
improve the
motor
neonate's feeding
difficulties or
skills and overall
feeding
nutritional intake.
aversions in the
neonate.

1. **Assessment:**
 - Assess respiratory rate, depth, and effort.

- Monitor oxygen saturation levels using pulse oximetry.

- Evaluate color and skin temperature.

- Assess for signs of respiratory distress such as nasal flaring, grunting, or retractions.

2. **Diagnosis:**

- Risk for impaired gas exchange related to immature respiratory system secondary to prematurity or respiratory distress syndrome (RDS).

3. **Planning:**

- Maintain adequate oxygenation and ventilation.

- Prevent respiratory complications.

- Promote optimal respiratory function.

4. **Interventions:**

- Position the newborn in a neutral position to maximize lung expansion.

- Provide a warm and quiet environment to minimize energy expenditure.

- Administer oxygen therapy as prescribed, monitoring oxygen saturation levels closely.

- Maintain proper humidity levels to prevent drying of the respiratory mucosa.

- Encourage skin-to-skin contact (kangaroo care) with the mother to promote bonding and stabilize the newborn's respiratory rate.

- Monitor fluid balance to prevent fluid overload, which can worsen respiratory distress.

- Educate parents on signs of respiratory distress and when to seek medical assistance.
 - Collaborate with the healthcare team to ensure timely interventions and adjustments to the treatment plan.

5. **Evaluation:**

- Monitor the newborn's response to interventions.

- Assess improvements in respiratory status.

- Evaluate oxygen saturation levels and respiratory rate.

- Adjust the care plan as needed based on the newborn's progress and response to treatment.

Remember, the care plan should be tailored to the specific needs of the newborn and modified based on ongoing assessments and changes in
the clinical condition. Regular communication with the healthcare team and involving the parents in the care process are essential for optimal
outcomes.

1. **Assessment:**
 - Evaluate the newborn's ability to swallow effectively.

- Assess for conditions predisposing the newborn to aspiration such as prematurity, neurological impairment, or congenital anomalies.

- Monitor for signs of aspiration such as coughing, choking, cyanosis, or respiratory distress during or after feeding.

2. **Diagnosis:**

- Risk for aspiration related to immature swallowing reflexes or underlying medical conditions.

3. **Planning:**

- Prevent aspiration episodes during feeding.

- Monitor feeding techniques and oral motor function.

- Educate caregivers on safe feeding practices.

4. **Interventions:**

- Position the newborn in an upright position during feeding to reduce the risk of aspiration.

- Use appropriate feeding techniques, such as pacing and proper nipple selection, to facilitate safe swallowing.

- Monitor the newborn's ability to coordinate sucking, swallowing, and breathing during feeding.

- Assess for signs of feeding intolerance or respiratory distress during and after feeding.

- Consider alternative feeding methods if oral feeding is contraindicated, such as nasogastric or orogastric tube feeding.

- Educate parents on signs of aspiration and the importance of proper feeding techniques.

- Collaborate with speech therapists, occupational therapists, or other healthcare professionals as needed for feeding assessments and
interventions.
5. **Evaluation:**

- Monitor the newborn's response to feeding interventions.

- Assess for signs of aspiration during and after feeding.

- Evaluate the effectiveness of feeding techniques in preventing aspiration episodes.

- Adjust the care plan as needed based on the newborn's feeding tolerance and respiratory status.

Regular reassessment and communication with the healthcare team are essential for identifying and addressing any changes in the newborn's
condition or feeding abilities. Involving parents in the care process and providing them with support and education can help promote safe
feeding practices and reduce the risk of aspiration.

1. **Assessment:**
 - Monitor the newborn's temperature regularly, preferably using a calibrated thermometer.

- Assess the newborn's skin color, temperature, and overall physical condition.

- Evaluate environmental factors such as room temperature and humidity.

- Assess for risk factors predisposing the newborn to hypothermia, including prematurity, low birth weight, and inadequate clothing or
blankets.

2. **Diagnosis:**

- Risk for hypothermia related to immature thermoregulatory mechanisms and environmental factors.

3. **Planning:**

- Maintain the newborn's body temperature within normal range.

- Prevent heat loss and promote thermoregulation.

- Monitor for signs of hypothermia and intervene promptly if necessary.

4. **Interventions:**

- Ensure a warm environment by adjusting room temperature and minimizing drafts.

- Dry the newborn thoroughly after birth and during diaper changes to prevent evaporative heat loss.

- Use radiant warmers or incubators for preterm or low-birth-weight newborns to maintain body temperature.

- Dress the newborn in appropriate clothing, including hats and socks, to minimize heat loss from the extremities.

- Use skin-to-skin contact (kangaroo care) with the mother to provide warmth and promote bonding.

- Encourage early initiation of breastfeeding to provide additional warmth and support thermoregulation.
 - Monitor the newborn's temperature closely, especially during the first few hours after birth and during procedures or interventions that may
increase heat loss.

- Educate parents on signs of hypothermia and the importance of keeping the newborn warm, especially during the first few days of life.

5. **Evaluation:**

- Monitor the newborn's temperature and overall well-being regularly.

- Assess for signs of hypothermia, such as cool skin, lethargy, or poor feeding.

- Evaluate the effectiveness of interventions in maintaining the newborn's body temperature within normal range.

- Adjust the care plan as needed based on the newborn's response to interventions and changes in environmental conditions.

Regular assessment and monitoring are crucial for early detection and prevention of hypothermia in newborns. Collaboration with the
healthcare team and involvement of parents in the care process can help ensure optimal outcomes and reduce the risk of complications
associated with hypothermia.

1. **Assessment:**
 - Monitor the newborn's respiratory rate, depth, and effort.

- Assess oxygen saturation levels using pulse oximetry.

- Evaluate the newborn's color, skin temperature, and capillary refill time.

- Look for signs of respiratory distress such as nasal flaring, grunting, retractions, or cyanosis.

2. **Diagnosis:**

- Risk for impaired gas exchange related to underdeveloped respiratory system secondary to prematurity, meconium aspiration syndrome,
respiratory distress syndrome (RDS), or other respiratory conditions.

3. **Planning:**

- Maintain adequate oxygenation and ventilation.

- Prevent respiratory complications.

- Promote optimal respiratory function.

4. **Interventions:**

- Position the newborn in a neutral position to maximize lung expansion.

- Provide a warm and calm environment to minimize stress and energy expenditure.

- Administer supplemental oxygen as prescribed, monitoring oxygen saturation levels closely.

- Monitor fluid balance to prevent dehydration, which can thicken respiratory secretions and impair gas exchange.

- Encourage and assist with breastfeeding or feeding to prevent aspiration and promote nutrition for optimal respiratory function.

- Implement respiratory therapies such as chest physiotherapy or suctioning as indicated.

- Collaborate with the healthcare team to ensure timely interventions and adjustments to the treatment plan.

5. **Evaluation:**

- Monitor the newborn's response to interventions.

- Assess improvements in respiratory status.

- Evaluate oxygen saturation levels, respiratory rate, and effort.

- Adjust the care plan as needed based on the newborn's progress and response to treatment.

Regular reassessment and collaboration with the healthcare team are essential for providing effective care to newborns at risk for impaired gas
exchange. Involving parents in the care process and providing them with education and support can also improve outcomes and promote family-
centered care.

Disaturation, feeding intole, apnea (Necrotizing enterocolitis)

1. **Assessment:**
 - Monitor vital signs including temperature, heart rate, and respiratory rate.

- Assess skin integrity, looking for signs of redness, warmth, swelling, or drainage.

- Observe for signs of infection such as fever, lethargy, poor feeding, or irritability.

- Review maternal history for any risk factors for infection during pregnancy or delivery.

2. **Diagnosis:**

- Risk for infection related to immature immune system, invasive procedures, or prolonged rupture of membranes during labor.

3. **Planning:**

- Prevent infection transmission.

- Monitor for signs and symptoms of infection.

- Provide appropriate treatment if infection is suspected.

4. **Interventions:**

- Maintain strict hand hygiene before and after handling the newborn.

- Educate parents and caregivers on hand hygiene techniques.

- Ensure proper cleansing and disinfection of equipment and surfaces in the newborn's environment.

- Implement strict aseptic techniques during invasive procedures such as venipuncture or catheter insertion.

- Promote breastfeeding to provide passive immunity and enhance the newborn's immune response.

- Monitor for signs of infection such as fever, tachycardia, or respiratory distress.

- Obtain cultures as indicated and administer antibiotics promptly if infection is suspected or confirmed.
 - Encourage early immunizations according to the recommended schedule.

- Educate parents on signs and symptoms of infection and when to seek medical attention.

- Collaborate with the healthcare team to implement infection control measures and coordinate care.

5. **Evaluation:**

- Monitor the newborn's temperature and vital signs regularly.

- Assess for signs and symptoms of infection.

- Evaluate the effectiveness of infection prevention measures.

- Adjust the care plan as needed based on the newborn's response to treatment and changes in clinical status.

Regular assessment, vigilant monitoring, and prompt intervention are essential for preventing and managing infections in newborns.
Collaboration with the healthcare team and providing support and education to parents can help ensure optimal outcomes and reduce the risk
of complications associated with neonatal infections.