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Careplan NewBorn

A 54 hour old female newborn born via caesarean section at 38.1 weeks gestation to a married 38 year old mother was assessed. The newborn had Apgar scores of 8 and 9 at 1 and 5 minutes, respectively, and no complications. The nursing care plan addressed the risk of injury during transition to extrauterine life. Interventions included constant supervision when out of the crib and using proper lifting technique to support the head and prevent falls or drops. The goal of no physical injury during the 12 hour shift was met.

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Vic Dang
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2K views2 pages

Careplan NewBorn

A 54 hour old female newborn born via caesarean section at 38.1 weeks gestation to a married 38 year old mother was assessed. The newborn had Apgar scores of 8 and 9 at 1 and 5 minutes, respectively, and no complications. The nursing care plan addressed the risk of injury during transition to extrauterine life. Interventions included constant supervision when out of the crib and using proper lifting technique to support the head and prevent falls or drops. The goal of no physical injury during the 12 hour shift was met.

Uploaded by

Vic Dang
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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Texas Womens University

Womens Health and Family Concepts N3025


Nursing Care Plan: Nursing Process Format
1. Student Name: My Dang
extrauterine life
Patient Type Newborn

Date Care Provided: 10/01 1.

Patient Age 54 hour age

Delivery Date 09/29 at 0204 CDT


Newborn: Sex Female
DATA

Risk of injury R/T normal physiologic transition from intrauterine life to

Marital Status Maried, spouse present

Gravida 2 TPAL 1001

Type of Delivery Caesarean section

Prenatal Complications None

Age 38.1 weeks Birth Wt. 3110 g Apgar Score(s) 8 1mins, 9 5mins
DIAGNOSIS

EDC 10/12/2015

GOALS

bottle feeding

INTERVENTIONS

Newborn Complications none


RATIONALE

EVALUATION/PATIENT
OUTCOME

Because infants can


fall from beds and
other surfaces if left
alone. (p 714)

Goal met, infant is free


from injury during 12h
shift

Subjective: n/a

Objective
caesarean section
newborn,
Early term (38.1
weeks)

2. Risk of
injury R/T
newborn

1. Infant will not


experience
physical injury
during 12h shift
what injury? Be specific
how do I measure this

Always keep an eye


and hand on the
newborn when he or
she is out of the crib
Observe for subtle
signs of neurologic
changes, assess for
jaundice, monitor vital
signs

.
Using appropriate
technique: picked up
by sliding one hand
under the neck and
shoulder and the other
hand under the buttock
or between the legs,
then gently lifting the
newborn during

Respirator
change, color
change,
temperature
instability,
Jitteriness,
irritability,
abnormal
movement or
difficult to waken,
lethargy are signs
of neonatal
distress (p 712)
This technique
provide security
and support for
the head (which
the baby is unable
to consistently
support until 3 or
4 months of age)
(p 719)

assessment or feeding
to prevent injury
List references used

References
Davidson, M. (2016). Maternal-Newborn Nursing & Women health across the life span (10 ed.).p712,
714, 719. Pearson.

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