- Imbalanced Nutrition: Less Than Body Requirements
- Risk for Hypothermia
- Risk for Impaired Gas Exchange
- Risk for Impaired Skin Integrity
- Risk for Infection
Nursing Process
Nurses are expected to evaluate and monitor the neonate as part of a newborn assessment. This includes an Apgar score, which is a rapid assessment of respiratory and heart rate, muscle tone, reflexes, and color. Later measurements will include height and weight and lab tests.
Nurses are also a source of education and support to new parents as they transition into parenthood. The nurse assists parents in feeding, bathing, and learning to respond to the newborn’s cues.
Nursing Care Plans
Once the nurse identifies nursing diagnoses related to the care of newborns, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for newborns.
Imbalanced Nutrition: Less Than Body Requirements
Imbalanced nutrition in newborns can occur due to various reasons, including inadequate breast milk, chronic illnesses, infections, environmental factors, genetics, neglect, and insufficient parental knowledge.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related to:
- Inadequate breast milk intake
- Inadequate knowledge of breast milk requirements
- Inadequate breast milk production
- Ineffective breastfeeding
- Interrupted breastfeeding
- Underlying health condition
- Prematurity
As evidenced by:
- Body weight below the ideal weight range for age and gender
- Inadequate height increase for age and gender
- Inadequate head circumference growth for age and gender
- Neonatal weight gain < 30 g (1 ounce) per day
- Constipation
- Poor output
- Pale mucous membranes
- Lethargy
- Muscle hypotonia
Expected outcomes:
- 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.
Assessment:
1. Assess the frequency and duration of breastfeeding.
While mothers may choose to bottle feed for a variety of reasons, the newborn should be fed 8-12 times for the first month. Most breastfed babies will feed every 2 to 4 hours and nurse for 10 to 15 minutes on each breast.
2. Assess the newborn’s ability to feed.
Newborns who are sick or premature have significantly higher demands when it comes to nutrients and energy and may exhibit difficulties with feeding by mouth due to decreased intestinal maturation and reduced coordination with sucking, swallowing, and breathing.
3. Assess the parent’s knowledge about feeding cues.
Ensure the parents are aware of feeding cues the infant will display when hungry. These include lip smacking, sticking out their tongue, rooting, and putting a fist in their mouth. Crying is often a late sign of hunger.
Interventions:
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.
Risk for Hypothermia
Risk for Hypothermia in a newborn is related to a high surface area to volume ratio. This ratio is higher in low-birth-weight newborns, causing rapid heat loss and hypothermia. It can also be caused by the transition from a warm environment inside the uterus to one that is considerably cooler.
Nursing Diagnosis: Hypothermia
Related to:
- Large surface area compared to mass
- Inadequate insulating subcutaneous fat
- Exhaustible brown fat sources
- Few white fat reserves
- Thin epidermis susceptible to increased heat loss
- Inability to shiver
- Infectious process
- Impaired thermoregulation
- Environmental concerns
- Cesarean delivery
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Newborn will be able to maintain a body temperature within normal limits.
- Parents/caregiver will verbalize the understanding of hypothermia and its prevention.
Assessment:
1. Monitor the newborn’s body temperature.
Accurate temperature measurement is necessary to ensure correct diagnosis and interventions. Newborn temperatures should be measured rectally for the most accurate assessment. Educate the parents/caretakers on how to properly check the temperature. A temperature below 97.7 F (36.5 C) is below normal.
2. Assess risk factors.
Low-birth weight, prematurity, and poor thermoregulation due to sepsis or drug withdrawal can increase the risk of hypothermia.
3. Monitor for cold stress.
Cold stress results in severe metabolic and physiological problems. Oxygen consumption and calorie expenditure occur in the newborn’s attempt to produce heat. If this is prolonged it can impair growth.
Interventions:
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.
Risk for Impaired Gas Exchange
Risk for impaired gas exchange can be caused by delayed or poor adaptation to life outside the uterus. It may also be caused by pre-existing conditions like congenital defects, or acquired disorders like lung infections that develop before or after delivery.
Nursing Diagnosis: Risk for Impaired Gas Exchange
Related to:
- Low lung function and compliance
- Significant increased metabolic rate
- The tendency for reduced functional residual capacity (FRC)
- Increased resistance by excess production of mucus
- Cold stress
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- 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.
Assessment:
1. Assess the client’s respiratory status.
The respiratory assessment reflects the effectiveness of alveolar ventilation. Low Pao2 levels may indicate the need for ventilatory support.
2. Note the presence of symptoms of labored breathing.
Observe for nasal flaring, grunting, chest wall retractions, and cyanosis. These symptoms may suggest increased oxygen usage and energy expenditures.
3. Review the results of hemoglobin and arterial blood gas (ABG) tests.
ABGs are influenced by the newborn’s respiratory, circulatory, and metabolic processes. Hemoglobin levels show the status of the oxygen-carrying capacity of the blood.
4. Assess the newborn’s caregiver’s knowledge of identifying symptoms of respiratory distress.
The parents/caregiver need to be aware of the infant’s expected behaviors, responses, and activities. Newborn respiratory distress includes tachypnea, nasal flaring, periods of apnea, cyanosis, noisy breathing, grunting, and chest retractions.
Interventions:
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.
Risk for Impaired Skin Integrity
Newborn skin problems like diaper rash and cradle cap are common. It is important to educate on the prevention and treatment of non-intact skin to prevent infection.
Nursing Diagnosis: Risk for Impaired Skin Integrity
Related to:
- Inadequate caregiver knowledge about maintaining tissue integrity
- Malnutrition
- Fluid and electrolyte imbalance
- Thermoregulation problems
- Moisture
- Immunodeficiency
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Newborn will maintain an intact skin appearance with adequate skin turgor.
- Caregiver will verbalize understanding and demonstrate interventions that promote newborn skin health.
Assessment:
1. Assess the infant’s skin characteristics and condition.
Proper skin assessment can help identify potential developing skin problems so prompt interventions can be provided.
2. Assess the parent’s knowledge about proper skin care for newborns.
This will help gauge the caregiver’s ability to prevent and reduce the risks of impaired skin integrity in newborns and will help determine the appropriate approach in providing patient education and treatment.
Interventions:
1. Encourage the use of appropriate infant cleansers.
The newborn skin must be kept clean and dry at all times. Bathing is essential to ensure clean skin and appropriate infant cleansing products must be used. Newborns only require a bath 2-3 times per week.
2. Change diapers immediately.
When the newborn’s skin is exposed to urine and feces, it can cause impaired skin integrity, discomfort, skin irritation, and infection. Change diapers as soon as the baby urinates or has a bowel movement. Avoid perfumed baby wipes or those that contain alcohol. Zinc-oxide diaper creams may be used to relieve redness.
3. Encourage the parents to limit the newborn’s sun exposure.
Sun exposure must be limited to reduce newborns’ risk of impaired skin integrity. The newborn’s skin is very sensitive to UV rays and can easily burn. Incorporate the use of sun clothing and hats when outside. Sunscreen safety has not been studied by the FDA for infants under six months of age.
4. Encourage the mother to avoid applying skin care products to newborns’ skin.
A newborn’s skin is highly absorbent and sensitive. Avoid perfumes and dyes that can irritate the skin. For premature infants, the skin does not hold moisture well, and petroleum jelly will help protect the skin.
5. Instruct on when to seek further assistance.
Most instances of newborn skin issues only require mild interventions. If skin conditions persist or worsen or the infant shows signs of infection (fever, drainage), the parent should contact the pediatrician.
Risk for Infection
Risk for Infection is related to the increased susceptibility to infection. The newborn’s immune system is immature and can not yet protect against pathogens – at least for the first few months.
Related to:
- Inadequate acquired immunity
- Deficiency of neutrophils and specific immunoglobulins
- Environmental exposure
- Broken skin
- Traumatized tissues
- Decreased ciliary action
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Parents/caregiver will verbalize two infection prevention or risk reduction measures.
- Parents/caregiver will demonstrate a protected environment for the newborn.
- Patient will remain free from infection.
Assessment:
1. Assess for contributing factors.
Risk factors for infection include an immature immune system and underlying disease. Newborns are more susceptible to disease and infection because of inadequate immunoglobulin levels (IgA, IgE, and IgD). Prematurity, congenital defects, and maternal complications such as premature rupture of membranes (PROM) or delivery trauma increase the risk of infection.
2. Assess for presence or absence of immunity.
Natural immunity is required to prevent the recurrence of a particular disease. It is developed through the production of antibodies following infection. Certain communicable diseases can be prevented with passive immunization (such as immunoglobulin administration) and active immunization (such as vaccination).
3. Monitor for symptoms of infection.
Poor feeding, trouble breathing, fever, prolonged crying, and irritability are indications of an infection.
Interventions:
1. Ensure strict compliance to infection control and hand hygiene.
Hand washing is the primary protection against healthcare-associated illnesses. When providing care and especially with invasive interventions, the nurse must follow strict infection prevention to safeguard the newborn against infection.
2. Encourage breastfeeding.
While a personal choice, mothers who desire to breastfeed should be encouraged and instructed to do so. Breast milk contains natural immunoglobulins necessary to protect newborns against preventable infections.
3. Monitor caregivers and visitors for any existing illnesses.
To prevent exposure and transmission risk, encourage sick guests to avoid contact with the newborn. Caregivers or visitors may wear masks to further prevent the transmission of bacteria or viruses.
4. Provide health teaching about infection control measures.
Educate parents and caregivers to consistently practice infection control measures such as proper hand hygiene. Limit public outings during the first few weeks. Recommend necessary vaccinations. Provide educational materials and demonstrations as necessary.
References
- Berman, A., Snyder, S., & Frandsen, G. (2016). Promoting Health from Conception Through Adolescence. In Kozier and Erb’s fundamentals of nursing: Concepts, practice, and process (10th ed., pp. 330-335). Prentice Hall.
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Gallacher, D. J., Hart, K., & Kotecha, S. (2016). Common respiratory conditions of the newborn. Breathe, 12(1), 30-42. https://doi.org/10.1183/20734735.000716
- Nettina, S. M. (2019). Pediatric Primary Care. In Lippincott manual of nursing practice (11th ed., pp. 3223-3224). Lippincott-Raven Publishers.
- Silvestri, L. A., & CNE, A. E. (2019). Care of the Newborn. In Saunders comprehensive review for the NCLEX-RN examination (8th ed., pp. 810-826). Saunders.
