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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Objective:

Crying

unable to feed

cold roomtemperature

Disorganized infantbehavior related to coldroom temperature

After 2 hours of nursingintervention:The newborn will have a

good behavior

monitor body temperature every 1to 3 hours

monitor and record neurologic

status every 1 to 4 hours Maintain thermal neutral

environment and avoid situationthat might predispose the infant toheat loss, such as cool air, drafts,bathing and cold beddings.

Provide heat/warm of newbornusing swaddling, droplight andskin-to-skin contact.

After 2 hours of nursingintervention:The newborn had a good

behavior

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Objective:

Temperature of35.8

Ineffective

thermoregulationrelated to immaturetemperature controland decreasedsubcutaneous bodyfat

After 2 hours of nursing intervention:

The newborn will maintain temperatureand prevent hyperthermia and coldstress.Goals:

Long-term:Newborn will be able to sustainadequate/normal self thermoregulation.Short-term:Provide assistance and support tomaintain adequate normal temperature

Monitor axillary temperature

at least every 1 hour Provide heat/warm of

newborn using swaddling,droplight and skin-to-skincontact.

Maintain thermal neutralenvironment and avoidsituation that mightpredispose the infant to heatloss, such as cool air, drafts,bathing and cold beddings.

After 2 hours of nursing

intervention:The newborn maintainedtemperature and preventhyperthermia and coldstress.Goals:

Long-term:Newborn was able tosustain adequate/normalself thermoregulation.Short-term:

Provides assistance andsupport to maintainadequate normaltemperature

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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Objective:

RR: 67

Small forgestational age

Altered chestexcursion

Accessorymuscle use

Dyspnea

Nasal flaring

retractions

Ineffective breathingpattern related toadjustment toextrauterine existence

After 1 hour of nursingintervention:The newborn will be toadjust to his extrauterinelife

Goals:Long-term:Newborn will be maintainhis adjustment toextrauterine lifeShort-term:Provide assistance andsupport to maintainnormal respiratory status

obtain vital signs every 1 hour

suction ororpharynx andnasopharynx as needed

provide oxygen as needed

.maintain neutral environment

After 1 hour of nursingintervention:The newborn was be toadjust to his extrauterinelife

Goals:Long-term:Newborn was be maintainhis adjustment toextrauterine lifeShort-term:Provides assistance andsupport to maintainnormal respiratory status

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Objective:

Presence ofsucking reflexPresence ofrooting reflex

Readiness for

enhance nutritionrelated to theattitude towardsthe feeding bottle

After 8 hours of nursing intervention:

The newborn will be able to be ready forthe enhancement of his nutritionGoals:

Long-term:Newborn will be able to enhance hisnutrition.Short-term:Provide assistance and support tomaintain to enhance his nutrition

Determine

patterns ofhunger andsatiety

Obtain safepreparation andstorage of food

After 8 hours of nursing

intervention:The newborn was able to be readyfor the enhancement of hisnutritionGoals:

Long-term:Newborn was able to enhance hisnutrition.Short-term:Provides assistance and supportto maintain to enhance his

nutrition