- Imbalanced Nutrition less than Body Requirements related to Inadequate breast milk intake and Underlying health condition Prematurity as evidenced by Body weight below the ideal weight range for age and gender
- Impaired thermoregulation hypothermia related to large surface area compared to mass and thin epidermis susceptible to increased heat loss as evidenced by decreased body temperature
- Risk for Impaired Gas Exchange related to Low lung function and compliance and Increased resistance by excess production of mucus due to cold stress as evidenced by nasal flaring and chest wall retractions
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Mother Verbalizes Inadequate breast milk production and Ineffective breastfeeding Objective Data: Inadequate head circumference growth for age and gender Neonatal weight gain < 30 g (1 ounce) per day | Imbalanced Nutrition less than Body Requirements related to Inadequate breast milk intake and Underlying health condition Prematurity as evidenced by Body weight below the ideal weight range for age and gender | Newborn will gain at least 5 to 7 ounces per week for the first three months of life. Newborn will exhibit signs of nutrition and hydration as evidenced by 6-8 wet diapers per day, sleeping well, and alertness when awake. | 1. Instruct the mother on breastfeeding positions and latching. Assess for any breast complications like mastitis or engorgement that interrupt breastfeeding. Aid the mother in finding the most comfortable positions to support breastfeeding. Observe the mother and infant for latching difficulties. Proper latching will not hurt. The nipple should be high and deep in the mouth with the mouth open wide and the lower lip turned outward against the breast. The chin is touching the breast, and the nose is very close. The mother will hear the infant suck and swallow. 2. Monitor the baby’s weight, growth, and development. Newborn babies lose approximately 10% of their weight after birth and regain it within one to two weeks. Infants should gain five to seven ounces per week until about four months when weight gain starts to slow. 3. Educate how to express and store breast milk if breastfeeding is not possible. Expressed breast milk through pumping can still provide infants with the nutrients and antibodies of breast milk if breastfeeding is difficult. 4. Monitor the newborn’s hydration and overall health status. Dehydration can further affect newborn nutrition and overall well-being. Monitor the newborn’s fontanelles, skin turgor, mucous membranes, and urine and stool output. It is also important to note signs of lethargy and weakness in newborns, as this can signal inadequate nutrition. 5. Offer resources as needed. Women, Infants, and Children (WIC) is a federally funded nutrition program that provides food, nutrition counseling, and breastfeeding support for free. Women who meet low-income requirements can receive food and formula for themselves and their infants to support nutrition. | Patient maintained weight in desired goal range. Patient mother recognized factors that are contributing to being under or overweight. Patient mother identified appropriate nutritional needs/requirements. Patient mother made baby to consume adequate nutrition. Patient mother verbalized appropriate management of nutrition at home. |
| Subjective Data: Mother Verbalizes baby has decreased body temperature Objective Data: -Hypothermia -Thin Epidermis | Impaired thermoregulation hypothermia related to Large surface area compared to mass and thin epidermis susceptible to increased heat loss as evidenced by decreased body temperature | Newborn will be able to maintain a body temperature within normal limits. Parents/caregiver will verbalize the understanding of hypothermia and its prevention. | 1. Keep the newborn dry and tightly wrapped in a blanket. The newborn may lose heat quickly as a result of wet skin. The baby should be quickly dried and swaddled. 2. Provide heat loss barriers. Newborns, especially preterm and/or low-birth-weight infants, require barriers to prevent heat loss. Vigorous rewarming while regularly monitoring temperature is needed. Blankets, isolettes, and radiant warmers can be utilized. Encourage skin-to-skin contact of the newborn with the mother. Studies have shown that this helps minimize the risk of hypothermia. 3. Provide a warm environment. The newborn has not acquired extra adipose tissue to act as insulation and is not able to shiver to warm the body naturally. Therefore, newborns cannot regulate their temperature. Newborns can lose heat nearly 4 times quicker than an adult. If the room temperature is too low, even healthy, full-term newborns may struggle to stay warm. 4. Provide education to the parents/caregiver. Newborns struggle to adjust to temperature changes. The nurse may inform parents/caregivers about the dangers of hypothermia and hyperthermia. Explain the importance of a newborn’s thermal protection. Ensure the newborn’s routine care includes the prevention of hypothermia. Demonstrate and supervise activities such as bathing and swaddling. | The patient’s core body temperature restored to within the normal range, as evidenced by a temperature reading of 36.5-37.5°C (97.7-99.5°F), within [specified time frame]. The patient maintained adequate peripheral circulation, as evidenced by palpable peripheral pulses and normal capillary refill time of less than 3 seconds. The patient demonstrated understanding of preventive measures to avoid future episodes of hypothermia, as evidenced by verbalization of appropriate clothing choices, shelter-seeking behaviors, and knowledge of environmental risks. |
| Subjective Data: -Dyspnea -Diaphoresis (excessive sweating) -Visual disturbances Objective Data: -Altered respiratory patterns -Restlessness -Lethargy -Cyanosis -Irritability -Abnormal arterial blood gas values or blood pH -Decreased oxygen saturation | Risk for Impaired Gas Exchange related to Low lung function and compliance and Increased resistance by excess production of mucus due to cold stress as evidenced by nasal flaring and chest wall retractions | Newborn will be able to maintain ABGs within normal limits. Newborn will be able to maintain oxygen saturation within normal limits. Newborn will remain absent of nasal flaring and chest wall retractions. | 1. Elevate the head of the bed. Breathing is easier in an elevated or upright position. This position promotes optimal chest expansion. It is also easier to assess the newborn in this position for any symptoms of respiratory distress. 2. Suction the airway as needed. A newborn may not be able to clear secretions on their own and may require suctioning if mucus is heard or observed. Measure patient’s pulse oximetry and vital signs to check for the effectiveness of suctioning. 3. Administer oxygen. Oxygen can be delivered through nasal cannula or face mask to aid in gas exchange. 4. Prepare equipment for emergency ventilation. Emergency ventilation supplies should always be available at the bedside. Suction catheters and an ET/tracheostomy set must be suitable for the size of an infant in preparation for opening the airway during an emergency. | Patient mother reported relief of dyspnea. Patient regained an oxygen saturation of greater than 90%. Patient manifested vital signs within normal limits. Patient presented signs and symptoms of improved ventilation. Patient demonstrated arterial blood gas (ABG) levels within normal limits. Patient had imaging scans with normal lung findings. |