Last updated on May 17th, 2022 at 08:01 am
Newborn Care Nursing Care Plans Diagnosis and Interventions
Newborn NCLEX Review and Nursing Care Plans
Newborns are among the fascinating individuals that a person will ever meet in their lifetime. Everyone in the family is expected to be eager to hold and cuddle this newly arrived cute little one. Wherever newborns go, they continue to bring delight and excitement to everybody.
Everyone is also concerned about the newborn’s health, so learning about the newborn’s typical profile and activities is a decent idea. Nurses are one of the first healthcare practitioners to interact with them when they are delivered. Thus, it is up to the nurses to offer the best nursing care possible before handing them over to their parents.
Newborn’s Profile and Assessment for Well-being
The evaluation of the newborn begins the instant they are delivered, and a variety of standard examinations are utilized for quick evaluation. Although newborns may appear to be identical, they each have their distinct physical characteristics and personality.
Vital Statistics of a Newborn
Newborns’ weight varies depending on race, genetics, and nutritional variables. During the first few days of life, the newborn loses about 5-10% of its birth weight. Then, within the first six months of life, the newborn must gain 2 pounds per month.
The infant’s length, head/chest/abdominal circumferences are also plotted to determine if any disproportions are present.
The average parameters that nurses use to examine the newborn’s vital statistics are listed below.
|Weight||6.5 to 7.5 lbs (2.9 kg to 3.4 kg)|
|Length||50 cm (20 in)|
|Head circumference||33 to 35 cm (13 to 13.7 in)|
|Chest circumference||31 to 33 cm or 2cm less than head circumference|
|Abdominal circumference||31 to 33 cm|
Vital Signs of the Newborn
One of the tasks that a healthcare provider does with a newborn is taking their vital signs. The acceptable vital signs measurements of a newborn are listed below.
|VITAL SIGNS||IMMEDIATELY AT BIRTH||AFTER BIRTH|
|Temperature||36.5 to 37.2 Celsius|
|Pulse||180 beats per minute||120-140 beats per minute|
|Respiration||80 cycles per minute||30-50 cycles per minute|
|Blood Pressure||80/46 mmHg||100/50 mmHg (by 10th day)|
Appearance of the Newborn
A newborn can have a variety of skin colors. As they grow older, the color of the skin that they were born with may change. In most cases, skin color variations in newborns do not usually signify an underlying condition. However, some skin colors may be due to certain health conditions.
A pink complexion upon birth is the healthiest color. But having only a pink body and blue extremities, also called acrocyanosis, is considered normal and healthy. Having a reddish complexion upon birth is also a common occurrence. This is caused by an increased concentration of red blood cells and a lower proportion of subcutaneous fat in newborns.
Other various skin colors, appearances, and remarkable characteristics of newborns are listed below, along with their interpretations.
- Pale and cyanotic (bluish discoloration) – indicates that the newborn may be suffering from a lack of control over his central nervous system or a manifestation of congenital heart defects.
- Gray color – an indication of an infection process
- Jaundice (yellowish discoloration) – If it emerges on the second or third day of life as a result of the disintegration of fetal red blood cells, it is deemed normal. Physiologic jaundice typically goes away after two to three days; early feeding may lessen it by speeding the passage of feces through the gut and preventing bilirubin reabsorption from the bowel.
- Pallor – a sign of anemia. Blood in the stool or vomitus in the newborn, a sign of anemia, must be continuously monitored.
- The Harlequin sign, which occurs when a newborn is resting on his or her side and appears red on one side and pale on the other, has no clinical relevance.
- Upon delivery, the newborn is normally covered in vernix caseosa, a white cream cheese-like substance. It is rinsed away in the first bath, but it should never be rubbed vigorously off as it will only come off gently.
- The lanugo, or fine, downy hair that covers the newborn’s shoulders, arms, and back, would be rubbed away typically by the friction of the bedding and garments.
- Milia is a white, tiny papule that appears on the cheek or bridge of the nose in certain newborns and disappears between 2 and 4 weeks of age.
The nurse conducts APGAR scoring to the newborn immediately after a few minutes of being born. The heart rate, respiration rate, muscle tone, reflex irritability, and color are the parameters to assess. The Apgar score serves as the starting point for all subsequent observations of a newborn.
The APGAR score is determined by evaluating the following parameters: Activity, Pulse, Grimace, Appearance, and Respiration of newborns. Each parameter can have a maximum value of two and a minimum score of zero. The scores of the five parameters are then summed to determine the newborn’s status.
|A – Activity||Absent||Flexed arms and legs||Active|
|P – Pulse||Absent||Below 100 bpm||Over 100 bpm|
|G – Grimace||Floppy||Minimal response to stimulation||Prompt response to stimulation|
|A – Appearance||Blue; pale||Pink body, blue extremities||Pink|
|R – Respiration||Absent||Slow & irregular||Vigorous cry|
The following are the total APGAR scores and their interpretations.
0-3 points: The newborn is in danger and needs to be resuscitated right away.
4-6 points: The newborn’s status is delicate, and he or she may require more extensive airway clearance and supplemental oxygen.
7-10 points: The newborn is deemed to be healthy and in good condition.
Silverman and Andersen index
Respiratory evaluation is required with every newborn interaction since it is the most important aspect of newborn care. The Silverman and Andersen index is used by nurses to determine the severity of respiratory distress. Chest movement, intercostal retraction, xiphoid retraction, nares dilatation, and expiratory grunt are the five criteria used to assess the newborn’s respiratory health.
Each criterion has a maximum score of 2 and a minimum value of 0. The lowest overall score is 0, indicating that no respiratory distress is present. A score of 4 to 6 suggests mild distress, whereas a score of 7 to 10 indicates severe respiratory distress. The Apgar scoring is opposite the Silverman and Andersen index scores.
Physical Examination of the Newborn
The respiratory evaluation is the most crucial assessment before anything else. But physical examinations are also performed on babies to detect any visible illnesses or physical deformities. The healthcare provider does this assessment swiftly while documenting crucial observations and avoiding overexposure of the newborn.
The height and weight of a newborn are part of the physical examination. They are used to measure the newborn’s maturity and provide baseline data. The newborn is weighed every day at the same time to detect any unexpected weight growth or loss.
Nursing Diagnosis for Newborn Baby
Nursing Care Plan for Newborn Baby 1
Risk for hyperthermia
Nursing Diagnosis: Risk for Hyperthermia related to developing thermoregulation
Desired Outcome: The patient will maintain normal body temperature as evidenced by an acceptable range of vital signs and normal white blood cells (WBC) count.
|Newborn Care Nursing Interventions||Rationale|
|Thoroughly observe the newborn’s health.||Through thorough observation of the newborn, a healthcare provider can identify the necessity for intervention, and the efficacy of treatment.|
|Closely monitor the vital signs of the newborn.||It is required to obtain baseline data and enables the healthcare provider to plan the next course of action.|
|Provide Tepid Sponge Bath as necessary.||It helps in cooling down the body temperature.|
|Ascertain that every equipment used to care for the newborn is sterile and immaculate. Do not share one’s equipment with other infants.||The spread of germs to the newborn is prevented by utilizing sterile equipment and not using the same equipment for every infant.|
|As directed by the attending physician, administer antipyretics.||Helps in quickly reducing the body temperature.|
Nursing Care Plan for Newborn Baby 2
Risk for Fluid Volume Deficit
Nursing Diagnosis: Risk for Fluid Volume Deficit related to the failure of regulatory mechanism.
Desired Outcome: The patient will be able to retain fluid volume at a functional level as evidenced by individually acceptable urine output with normal specific gravity, normal levels of electrolytes, stable vital signs, moist mucous membranes, good skin turgor, quick capillary refill, and firm and flat fontanelles.
|Newborn Care Nursing Interventions||Rationale|
|Monitor and document vital signs||To document significant changes in vital signs, such as a drop in blood pressure, an increase in pulse rate, and a rise in temperature.|
|Observe the contributing reasons to the fluid volume deficit.||To determine what factors lead to a fluid volume deficit of a newborn that can be treated immediately.|
|If the patient develops a fever, give him a tepid sponge bath||Body temperature is lowered, and comfort is provided to the newborn with a tepid sponge bath.|
|Administer oral care by moistening lips, as well as skin care by bathing on a regular basis.||Oral care is administered to avoid dryness-related injuries.|
|As directed by the attending physician, administer intravenous fluid replacement.||Intravenous fluid is used to replenish fluid losses of the newborn.|
|If the patient has a fever, give antipyretics as ordered by the physician.||To bring the body temperature down quickly as possible.|
Nursing Care Plan for Newborn Baby 3
Nursing Diagnosis: Risk for Ineffective Tissue Perfusion related to inadequate oxygen in the tissues or capillary membrane
Desired Outcome: The patient will exhibit enhanced perfusion as evidenced by warm and dry skin, strong peripheral pulses, acceptable vital signs, adequate urine production, and the absence of swelling.
|Newborn Care Nursing Interventions||Rationale|
|Monitor and record the characteristics and strength of peripheral pulses.||To assess a pulse that has grown weak or thready as a result of a below-normal level of oxygen in the newborn’s blood.|
|Evaluate the newborn’s rate, depth, and quality of breathing.||It’s worth noting that increased respiration happens in reaction to endotoxins’ direct effects on the brain’s respiratory center, as well as the development of hypoxia and stress. As respiratory insufficiency progresses, breathing might become shallow, putting the newborn at risk for acute respiratory failure.|
|Examine the newborn’s skin for color, temperature, and moisture changes.||To recognize if there are any compensating mechanisms for vasodilation.|
|Elevate affected/ edematous extremities every now and then.||Elevating the edematous extremities saves energy and reduces the need for oxygen.|
|Create a peaceful, relaxing environment for the newborn.||To allow the newborn to have enough rest so that the oxygen available for cellular uptake is maximized.|
Nursing Care Plan for Newborn Baby 4
Risk for Interrupted Breastfeeding
Nursing Diagnosis: Risk for Interrupted Breastfeeding related to the newborn’s present health condition
Desired Outcome: The mother must still be able to identify and demonstrate ways for maintaining lactation as well as techniques for providing breast milk to the newborn.
|Newborn Care Nursing Interventions||Rationale|
|Evaluate the mother’s perceptions and understanding of breastfeeding, as well as the amount of education she has received.||To find out what the mother already knows and the need for supplemental teaching.|
|Provide emotional support to the mother and accept her decision about whether or not to breastfeed.||To support the mother in continuing to breastfeed as preferred.|
|Demonstrate how to use a manual breast pump with a piston.||Support in the feeding of the newborn with breast milk when the mother is unable to do so.|
|Observe the methods for storing and using expressed breast milk.||To ensure appropriate nutrition and to encourage the continuation of the lactation process.|
|Check if a regular visitation schedule or early notice may be provided to the mother.||A proper visitation schedule when the infant is hungry and eager to be fed can make the newborn drink breast milk adequately.|
|When the mother is breastfeeding, ensure privacy and a peaceful environment.||A peaceful and private environment encourages successful newborn feeding.|
|Suggest to the mother that newborn feeding be made frequently.||Enhances digestion while reinforcing that feeding time is enjoyable.|
|Encourage the mother to get enough sleep, drink plenty of water and eat well, and breastfeed every three hours while awake.||To ensure that adequate milk production and the breastfeeding process are maintained.|
Nursing Care Plan for Newborn Baby 5
Risk for Impaired Parent/Newborn Attachment
Nursing Diagnosis: Risk for Impaired Parent/Infant Attachment related to newborn’s current health status and hospitalization.
Desired Outcome: After discharge, the mother will be able to recognize and show strategies to improve the newborn’s behavioral organization, and the parents will be able to have mutually satisfying interactions with their infant.
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.