Streamlined Patient Care Plan

NUR 4545 Women and Newborn Health Nursing

Student Name: ___Nancy De La Torre_____ Date of Care: _7/14/17_____

Focus of Care Plan: (highlight one) Labor/Birth Postpartum Newborn
Identifying information: Complete information for newborn AND mother on all care plans
NEWBORN Initials: __J.H.___ Birth date: __7/11/17__ Gestational age: _406__ Birth weight: _7lbs11oz__ Age (in hours): _61hours__
APGAR scores at birth: _____9____ Method of feeding: ____Breastmilk and formula______
Blood type: _information not available_ Coombs: _ information not available _ TCB or TBili: _3.5mg.dL__ Glucose: _ information not available_
MOTHER Initials: ___D.D._____ Gravida __1__ Para (term) __1__ (preterm) __0__ (abortions/miscarriages) __0__ (living children) __0__
Estimated date of delivery (“due date”): _7/8/17_ Prenatal Group B Strep: _______ Other abnormal prenatal labs: ______________
Blood Type: _______A positive_________ Type of anesthesia used during labor and/or birth (if applicable): ____Spinal_________
Episiotomy or laceration (describe by type and/or degree): __________________________________________
FOR ALL CARE PLANS
Type of birth: (circle) vaginal delivery Cesarean-section not delivered/born yet
Is there history of any high-risk situations or complications to previous pregnancy, labor/birth, or postpartum period? YES NO
If yes, please list: ________________no previous pregnancy______________________________________________________
Is there history of any complications to current pregnancy, labor, birth, postpartum, or newborn? YES NO
If yes, please list: _______________________________________________________________________________________________________

2017
Medications ordered for your patient:
Medication: Prescribed for:
Vitamin K Babies have low levels of vitamin K in their bodies at birth and can have severe bleeding. It is
needed for blood clotting. It is given to prevent a serious disease called haemorrhagic disease of
the newborn. This shot is usually given the first day of life.
Erythromycin 0.5% It is an antibiotic to help prevent gonorrhea and eye infections related to other bacteria that the
infant pics up as it goes through the birth canal that can also cause blindness. It kills the bacteria
that causes infections. This ointment is usually given the first day of life.
Mom refused Hepatitis B vaccine It’s a vaccine that prevents from the Hepatitis B virus that can cause infection and lead to
chronic infections of the liver and serious disease. Hepatitis B virus is transmitted from mother
to infant at the time of birth.

2017
 Nursing Diagnoses

List the top 3 nursing diagnoses for this patient. Use NANDA format (diagnosis, related to, as evidenced by) and place the diagnoses in their priority
order. Briefly discuss the rationale for this priority order.

Priority Nursing Diagnosis Related to As Evidenced By Rationale

1 Ineffective
thermoregulation
2 Risk for infection
Risk for imbalanced
3 nutrition
Newborn transition to
extrauterine life
Break in skin integrity at
umbilical site
Not receiving full colostrum
the first few days of life
Axillary temperature being
97.2 F.
Newly clamped umbilical cord.
Mom breastfeeding and bottle
feeding.
This is first priority because a big complication
can be cold stress which can lead to problems
such as depleted born far stores, increased
oxygen needs, respiratory distress, metabolic
acidosis, hypoxia and decreased surface
production.
This is not at highest priority but is still important
because frequent assessments of the area are
necessary. If bleeding or drainage is noted in the
area this is abnormal and can be a sign of
infection. In addition, signs of infection of the
umbilical cord stump can result in omphalitis.
This is the last priority since the newborn is still
receiving at least some natural nutrients through
her mother’s breastmilk rather than none at all.
The newborn is still receiving at least some
colostrum which is full in nutrients, low fat and
high in protein.

2017
Select the top two nursing diagnoses and complete a work-up table for each. PLEASE NOTE: the two diagnoses must be significantly different from each
other to demonstrate maximum learning.
Nursing Diagnosis #1: Ineffective thermoregulation related to newborn transition to extrauterine life as evidence by mom overcovering newborn.
Assessment or data collection
relative to the nursing diagnosis
(Provide thorough subjective and
objective assessments related to
diagnosis)
-Newborns temperature was 97.2F.
-Skin was cool to touch.
-There was very little clothing on
the newborn.
-Newborn was not on the heat
lamp.
-Newborn was not wearing a
“beanie” hat.
-Lack of subcutaneous fat.
2017
Patient Outcome
(objective, expected or desired
outcomes, or evaluation
parameters)
Remember the S-M-A-R-T acronym
-The newborn will maintain a
body temperature of 97.7F-99.5F
by discharge.
-The newborn will display no
signs and symptoms of cold
stress such as axillary
temperature below, poor
feeding, or cool to touch by
discharge.
Interventions/Implementations
and Rationale
(Write these as specific nursing
actions, beginning with an action
word)
-Monitor axillary temperature at
least every half hour or as
necessary.
-Place the newborn skin to skin
on the mother’s abdomen and
cover both with a blanket to
increase newborns body
temperature.
-Place a knit “beanie” on
newborns head.
-Swaddle newborn
-Dress the newborn with
appropriate clothing to promote
optimal body temperature.
Evaluation
(Evaluate the outcome/s and
include whether it was met or
unmet)
-After 8 hours of observation
the outcome was met. The
newborn maintain a body
temperature of 98.3F and was
discharge with mother at 1500
on 7/14/17.
-No signs and symptoms of
cold stress were observed on
newborn after 8 hours of
observations and the newborn
was discharged at 1500 on
7/14/17 The outcome was
met but the mom will still
continue to monitor and care
for newborn.
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 -Put the newborn under a heat
map to increase body
temperature.

-If none of these interventions

work call MD to inform them on
the situation.

2017 5
Nursing Diagnosis #2: Risk for infection related to skin integrity at umbilical site as evidence by newly clamped umbilical cord.
Assessment or data collection
relative to the nursing diagnosis
(Provide thorough subjective and
objective assessments related to
diagnosis)
-Umbilical site was covered with
clothing and blanket.
-Umbilical cord is clamped and cut
close to the belly button.
-Umbilical site is close the diaper
area.
-Umbilical site has no signs of
redness.
-No discharged was noticed.
-No bleeding was observed.
2017
Patient Outcome
(objective, expected or desired
outcomes, or evaluation
parameters)
Remember the S-M-A-R-T acronym
- The newborn will have a clean
and dry umbilical cord stump
until it falls off and heals which
can take around two weeks.
-The newborn will display no
signs and symptoms of
infections such as redness near
umbilical area, stump smells
foul, newborn cries when baby
cries when you touch the cord
or around the skin near it, and
the stumps has a yellow
discharge.
Interventions/Implementations
and Rationale
(Write these as specific nursing
actions, beginning with an action
word)
-Observe for any cord bleeding
drainage as this is a sign of
infection.
-Protect the cord during diaper
change.
-Avoid tub baths until the cord has
fallen off and the area is healed.
-Expose the cord air as much as
possible so it heals faster.
-If newborn is wearing clothing
make sure that it is loose to let air
circulate.
-Fold diapers below the level of
the cord to prevent
contaminations of the site.
-Observe to cord for color change
such as from yellow to brown to
black. This is normal.
Evaluation
(Evaluate the outcome/s
and include whether it was
met or unmet)
-This outcome is partially
met because the umbilical
site was dry and clean
throughout shift but it still
needs to be monitored until
it heals.
-The newborn displayed no
signs and symptoms of
infection while being
observed for 8 hours and
therefore the outcome was
met and the newborn was
discharged at 1500 on
7/14/17.
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 References

Ricci, S.S. (2017). Essentials of maternity, newborn, and women’s health nursing 4th ed.). Philadelphia: Lippincott Williams & Wilkins. 

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