S.

Assessment Nursing Expected Nursing Intervention Rational Implementation Evaluatio

No. Diagnosis Outcome n
1. Subjective Data: Hypotherm Neonate -Monitor the body -To check the intensity of -Body temperature is Neonate
Babys parents say ia r/t cold will have temperature. temperature. checked every hour by s temp.
their babys skin is stress as warm, dry axillary route. Returns
cool & pale. evidenced skin and to
Objective Data: by normal -Keep the baby warm. -To maintain the babys -Radiant warmer is normal.
Slow capillary increased capillary body temperature. used.
refill & cyanotic heart rate refill. -Room temperature is
nail beds. and blood maintained according
pressure. to the condition of the
-Monitor & record the -To check the degree of baby.
vital signs. hypothermia.
-Vital signs are
monitored & recorded
every 1 to 4 hrs.
-Continuous electronic
cardio respiratory
-Avoid precipitating -To prevent hypothermia. monitoring is
factors. performed as
. appropriate.

-Postponed bathing.
-Changed the wet
diapers promptly.
- -Performed all
 procedures under
radiant warmer as
possible.
-Advised the parents to
wear warm
clothes( according to
weather) to the
newborn baby to
prevent hypothermia .

S. Assessment Nursing Expected Nursing Intervention Rational Implementation Evaluatio

No. Diagnosis Outcome n

2. Subjective Data: Ineffective Mother - Educate the mother -To enhance - Mother is educated Mother
Patient feels breastfeedi will regarding breastfeeding. breastfeeding. regarding breast care & expresse
fullness and says ng due to express breastfeeding s
about crying of inadequate satisfactio -Encourage the mother techniques. satisfacti
baby within an sucking & n with for feed. -To reduce feeling of -Mother is encouraged on with
hour of swallowing breast fullness. during initial breast
breastfeeding. reflex feeding -Provide quiet & breastfeeding feeding
Objective Data: secondary technique comfortable episodes. practices
Inadequate milk to s& environment. -To promote successful -Quiet,private & .
supply. insufficient practice. breastfeeding. comfortable env. for
knowledge the mother &baby is
of provided so that
breastfeedi breastfeeding can be
ng to the -Answers the questions promoted.
mother. of mother & other family -To clear the doubts. -Mother is encouraged
members. to put questions & all
questions are clarified
3. regarding successful
Subjective Data: -Assess the knowledge feeding by giving the
Patient says that Risk of of mother for -To promote knowledge of appropriate answers.
there is problem in chocking Risk of breastfeeding. the mother. Risk of
feeding due to or feeding chocking -Give education on the -To promote easy passage -Knowledge of the chocking
inadequate problems will be techniques of of milk. mother is assessed for is
knowledge to due to reduced breastfeeding. - To prevent regurgitation. breastfeeding. reduced
mother about inadequate by giving -Give support to whole -Health education is by giving
feeding. sucking & education of babys body. given on techniques of educatio
Objective Data: swallowing on the -To promote bonding & breastfeeding. n on the
Babys mother reflex breast -Entire babys body attachment b/w mother & -Head, neck & back are breast
does not use secondary feeding. should face mother. baby. in same alignment feeding.
proper technique to -Burping reduces the risk during feeding.
of breastfeeding so insufficient -Give burping after the of aspiration. -Babys face is towards
baby does not suck knowledge feed. the mothers face.
properly. of
breastfeedi -Burping is done after
ng to the feeding.
mother.

NURSING PROCESS FOR NEWBORN BABY

List of diagnosis:
1. Hypothermia r/t cold stress as evidenced by increased heart rate and blood pressure.
2. Ineffective breastfeeding due to inadequate sucking & swallowing reflex secondary to insufficient knowledge of
breastfeeding to the mother.
3. Risk of chocking or feeding problems due to inadequate sucking & swallowing reflex secondary to insufficient
knowledge of breastfeeding to mother.

Health Education
Immunization: -Unimmunized Rh ve mothers who delivered Rh +ve babies are given Anti-D gamma globulin.
 -Women who are susceptible to rubella infection must be vaccinated & instructed about postponement of
pregnancy for at least 2 months .
-The booster dose of tetanus-toxoid should be given at the time of discharge, if it is not given during pregnancy.
Care of breasts: -The breasts should be examined daily, regardless of the chosen feeding method.
-Inspect the area of breast for redness.
-The mother should be instruct to give scrupulous attention to hand washing & hygiene to prevent infection.
-The nipples should be washed before & after each feeding.
-A nursing brassiere provides comfortable support so wear it.
Diet: -High protein diet should be taken by the mother. It is necessary for the physical growth of the baby.
-Iron rich diet will replenish the lose of blood.