Nursing Care Plan

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ASSESSTMENT| BACKGROUND KNOWLEDGE| PLANNING| INTERVENTION| RATIONALE| EVALUATION| Subjective:n/aObjective: * Preterm birth (36 weeks) * Weight: 1.75kgs. * Cool and dry skin. * Temperature: 33.6 degrees Celsius. * Poor muscle tone. * Placed under two droplights.Nursing Diagnosis: Ineffective thermoregulation related to immaturity.| Vaginal birthPretermPoor muscle developmenthypothermia| After 1 hour of nursing intervention,

patient will maintain
normal body
temperature from
36.5-37.5| (1)Monitor the neonate’s Body temperature until discharge(2) Dry newborn thoroughly and quickly and discard the wet blanket. Place the infant under pre warm radiant warmer(3) Avoid placing infant on cold surface or using cold instrument in

assessment.(4)ambient temperature
of the room where the
newborn is kept should
be monitored(5) Teach the mother about the infant’s need for warmth and to kept the infants head covered.(6) Teach family members about signs and symptoms of altered body temperature, such as cool extremities.(7) importance of contacting a health care

provider when problems related to temp.| (1)To determine the need for intervention n and the effectiveness of therapy.(2) Drying quickly and placing and placing on a warm, dry surface prevent heat loss.(3) Cold surface and instrument increase heat lossby conduction (4)to prevent excessive cooling.(5) the infants head provides a large surface area for heat loss.(6-7) Careful teaching allows family members to take an active role in maintaining the neonate’s health.| After 1 hour of

intervention, the
goal is fully met.
The neonate
maintained a
stable body
temperature at
36.7 C.|
CASE: Baby girl Mortel REMARKS: C.I.’s Sig.:AREA| AREA: DATE: September 17, 2010|
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