The initial months of life, often termed the newborn or neonatal period, are crucial as infants adapt to life outside the womb. This period involves significant physiological adjustments as newborns begin to breathe, suckle, swallow, digest, and eliminate waste independently. Throughout their first year, rapid development continues, with infants achieving numerous milestones through interaction with their environment.
Key physical milestones during this period include consistent weight gain, visual development, auditory development, and refined senses of smell, taste, and touch. Reflexes and motor development are also critical areas of progress.
The first week of a newborn’s life is particularly vulnerable, with a high percentage of neonatal deaths occurring during this time. Newborn mortality is frequently linked to factors such as preterm birth, complications during labor and delivery (like birth asphyxia), infections, and congenital anomalies.
Nursing Process
Nurses play a vital role in the comprehensive assessment and monitoring of newborns. This assessment begins immediately after birth with the Apgar score, a quick evaluation of respiratory effort, heart rate, muscle tone, reflexes, and skin color. Subsequent assessments include measurements of length and weight, along with necessary laboratory tests.
Beyond physical assessments, nurses are essential in providing education and support to new parents as they navigate the transition into parenthood. Nurses guide parents in essential newborn care practices, such as feeding, bathing, and understanding and responding to their newborn’s cues.
Nursing Care Plans
Once a nurse identifies relevant nursing diagnoses for newborn care, nursing care plans become indispensable. These plans prioritize assessments and interventions to meet both immediate and long-term healthcare goals for the infant. The following sections provide examples of nursing care plans tailored for newborns, focusing on common nursing diagnoses.
Imbalanced Nutrition: Less Than Body Requirements
Newborns can experience imbalanced nutrition for various reasons, including insufficient breast milk intake, underlying chronic conditions, infections, environmental influences, genetic predispositions, neglect, or inadequate parental knowledge regarding infant nutritional needs.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related Factors:
- Insufficient breast milk intake
- Lack of knowledge regarding infant feeding requirements
- Inadequate breast milk production
- Ineffective breastfeeding technique
- Interrupted breastfeeding
- Underlying health issues
- Prematurity
As evidenced by:
- Body weight below the expected range for age and gender
- Insufficient increase in height for age and gender
- Inadequate head circumference growth for age and gender
- Poor neonatal weight gain
- Constipation
- Reduced urine output
- Pale mucous membranes
- Lethargy
- Muscle hypotonia
Expected Outcomes:
- The newborn will achieve a weight gain of at least 5 to 7 ounces weekly for the initial three months of life.
- The newborn will demonstrate adequate nutrition and hydration, indicated by 6-8 wet diapers daily, restful sleep patterns, and alertness during waking hours.
Assessment:
1. Evaluate the frequency and duration of breastfeeding sessions.
While formula feeding is a valid choice, exclusively breastfed newborns should ideally feed 8-12 times within 24 hours during the first month. Typically, breastfed infants feed every 2 to 4 hours, nursing for approximately 10 to 15 minutes on each breast.
2. Assess the newborn’s feeding capabilities.
Newborns who are unwell or born prematurely have greater nutritional and energy demands. They might face challenges with oral feeding due to immature digestive systems and difficulties coordinating sucking, swallowing, and breathing.
3. Determine the parents’ understanding of infant feeding cues.
It is crucial to ensure parents can recognize early hunger cues from their infant. These cues include lip smacking, tongue protrusion, rooting motions, and bringing hands to the mouth. Crying is often a late indicator of hunger.
Interventions:
1. Educate the mother on effective breastfeeding positions and latch techniques.
Assess for any maternal breast complications like mastitis or engorgement that could hinder breastfeeding. Assist the mother in finding comfortable breastfeeding positions. Observe the breastfeeding dyad for latch difficulties. Proper latching should not be painful. The nipple should be positioned deeply within the infant’s mouth, with a wide mouth opening and the lower lip turned outwards against the breast. The infant’s chin should be touching the breast, and the nose should be close to the breast. Audible sucking and swallowing sounds from the infant indicate effective feeding.
2. Regularly monitor the infant’s weight, growth patterns, and developmental milestones.
Newborns typically experience a physiological weight loss of up to 10% after birth, regaining this weight within one to two weeks. Infants should gain approximately five to seven ounces per week until around four months of age, after which the rate of weight gain may naturally decrease.
3. Provide guidance on expressing and properly storing breast milk if direct breastfeeding is not feasible.
Expressed breast milk, obtained through pumping, can still offer newborns essential nutrients and antibodies if breastfeeding is challenging or not possible.
4. Monitor the newborn for signs of dehydration and overall health status.
Dehydration can further compromise newborn nutrition and overall well-being. Regularly assess the newborn’s fontanelles, skin turgor, mucous membranes, and urine and stool output. Be vigilant for signs of lethargy and weakness, which can indicate inadequate nutrition.
5. Connect families with relevant community resources as necessary.
The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a federally funded program providing nutritional support, food assistance, and breastfeeding education at no cost. Eligible low-income women can receive food and formula to support their nutritional needs and those of their infants.
Risk for Hypothermia
Newborns are at risk for hypothermia due to their large surface area relative to their body volume. This ratio is even more pronounced in low-birth-weight infants, leading to rapid heat loss and hypothermia. Transitioning from the warm intrauterine environment to a cooler external environment also contributes to this risk.
Nursing Diagnosis: Risk for Hypothermia
Related Factors:
- Large surface area relative to body mass
- Insufficient subcutaneous fat for insulation
- Limited reserves of brown fat for thermogenesis
- Minimal white fat reserves
- Thin epidermis, increasing heat loss
- Inability to shiver to generate heat
- Presence of infection
- Impaired thermoregulation
- Environmental factors (e.g., cold room temperature)
- Cesarean delivery
As evidenced by:
A risk diagnosis is identified by the presence of risk factors, not by signs and symptoms, as the problem has not yet occurred. Nursing interventions are focused on prevention.
Expected Outcomes:
- The newborn will maintain a body temperature within the normal range.
- Parents or caregivers will articulate their understanding of hypothermia and preventive measures.
Assessment:
1. Continuously monitor the newborn’s body temperature.
Accurate temperature measurement is vital for correct diagnosis and timely interventions. Rectal temperature measurement is recommended for newborns for the most accurate reading. Educate parents and caregivers on the proper technique for checking their baby’s temperature. A temperature below 97.7°F (36.5°C) is considered below normal.
2. Identify and assess individual risk factors for hypothermia.
Factors such as low birth weight, prematurity, and compromised thermoregulation due to sepsis or neonatal abstinence syndrome can significantly increase the risk of hypothermia.
3. Monitor for signs of cold stress.
Cold stress can lead to severe metabolic and physiological disturbances in newborns. To generate heat, newborns increase oxygen consumption and calorie expenditure. Prolonged cold stress can impair growth and development.
Interventions:
1. Ensure the newborn is thoroughly dried and warmly wrapped in a blanket immediately after birth and after bathing.
Newborns can lose heat rapidly from wet skin through evaporation. Promptly drying the baby and swaddling them in a warm blanket is essential.
2. Implement heat loss prevention strategies and provide external heat sources as needed.
Newborns, particularly those preterm or of low birth weight, require external barriers to minimize heat loss. If hypothermia occurs, vigorous rewarming is needed, accompanied by continuous temperature monitoring. Utilize blankets, incubators (isolettes), and radiant warmers as appropriate. Encourage skin-to-skin contact between the newborn and mother. Research indicates that skin-to-skin contact is effective in reducing the risk of hypothermia and promoting newborn temperature regulation.
3. Maintain a consistently warm environment.
Newborns lack sufficient adipose tissue for insulation and cannot shiver effectively to produce heat. Consequently, they are highly dependent on their external environment for temperature regulation and can lose heat up to four times faster than adults. Maintaining an adequately warm room temperature is crucial, even for healthy, full-term newborns, to prevent cold stress.
4. Educate parents and caregivers about thermoregulation and the prevention of hypothermia and hyperthermia.
Newborns have difficulty adapting to temperature fluctuations. Instruct parents and caregivers on the risks of both hypothermia and hyperthermia in newborns. Emphasize the importance of thermal protection as a routine part of newborn care. Demonstrate and supervise essential care activities, such as bathing and swaddling, ensuring they are performed in a manner that prevents hypothermia.
Risk for Impaired Gas Exchange
The risk for impaired gas exchange in newborns can arise from delayed adaptation to extrauterine life or from pre-existing conditions such as congenital defects or acquired disorders like lung infections that develop before or after birth.
Nursing Diagnosis: Risk for Impaired Gas Exchange
Related Factors:
- Reduced lung function and compliance
- Significantly elevated metabolic rate
- Tendency toward reduced functional residual capacity (FRC)
- Increased airway resistance due to mucus production
- Cold stress
As evidenced by:
A risk diagnosis is identified by the presence of risk factors, not by signs and symptoms, as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected Outcomes:
- The newborn will maintain arterial blood gas (ABG) values within normal limits for their age.
- The newborn will maintain oxygen saturation levels within the normal range.
- The newborn will exhibit no signs of respiratory distress, such as nasal flaring or chest wall retractions.
Assessment:
1. Regularly assess the newborn’s respiratory status.
Respiratory assessment is crucial for determining the effectiveness of alveolar ventilation. Low partial pressure of oxygen in arterial blood (PaO2) may indicate the need for respiratory support.
2. Monitor for signs and symptoms of labored breathing.
Observe for indicators of respiratory distress, including nasal flaring, grunting, chest wall retractions, and cyanosis. These signs suggest increased oxygen demand and energy expenditure.
3. Review laboratory results, including hemoglobin and arterial blood gas (ABG) values.
ABG values are influenced by the newborn’s respiratory, circulatory, and metabolic functions. Hemoglobin levels reflect the blood’s oxygen-carrying capacity.
4. Assess the parents’ or caregivers’ knowledge of recognizing respiratory distress symptoms.
Parents and caregivers need to be educated on the expected respiratory patterns and behaviors of newborns and how to identify signs of respiratory distress. Newborn respiratory distress may include tachypnea, nasal flaring, apneic episodes, cyanosis, noisy breathing, grunting, and chest retractions.
Interventions:
1. Elevate the head of the newborn’s bed or incubator slightly.
An elevated or upright position facilitates easier breathing by promoting optimal chest expansion. This position also improves visualization for assessing any signs of respiratory distress.
2. Suction the newborn’s airway as needed to clear secretions.
Newborns may not effectively clear airway secretions independently and might require gentle suctioning if mucus is audible or visible. Monitor the newborn’s pulse oximetry and vital signs before, during, and after suctioning to evaluate the procedure’s effectiveness.
3. Administer supplemental oxygen as prescribed.
Oxygen can be delivered via nasal cannula or face mask to support gas exchange and maintain adequate oxygenation.
4. Ensure availability of equipment for emergency ventilation.
Emergency ventilation equipment should always be readily accessible at the newborn’s bedside. Ensure that suction catheters and endotracheal/tracheostomy sets of appropriate infant sizes are available for immediate airway management in emergency situations.
Risk for Impaired Skin Integrity
Common skin issues in newborns, such as diaper rash and cradle cap, are frequently encountered. Education on preventing and managing skin breakdown is crucial to prevent secondary infections.
Nursing Diagnosis: Risk for Impaired Skin Integrity
Related Factors:
- Insufficient caregiver knowledge about maintaining newborn skin integrity
- Malnutrition
- Fluid and electrolyte imbalances
- Thermoregulation problems
- Exposure to excessive moisture
- Immunodeficiency
As evidenced by:
A risk diagnosis is identified by the presence of risk factors, not by signs and symptoms, as the problem has not yet occurred. Nursing interventions are focused on prevention.
Expected Outcomes:
- The newborn will maintain intact skin with good skin turgor.
- Caregivers will verbalize understanding and demonstrate appropriate interventions to promote newborn skin health.
Assessment:
1. Thoroughly assess the newborn’s skin characteristics and overall condition.
Detailed skin assessment aids in early detection of potential skin problems, enabling prompt intervention and preventive care.
2. Assess the parents’ knowledge regarding appropriate newborn skin care practices.
This assessment helps determine the caregiver’s ability to prevent and minimize risks to the newborn’s skin integrity, guiding the nurse in providing targeted education and support.
Interventions:
1. Recommend the use of gentle, pH-balanced infant cleansers.
Maintaining clean, dry skin is essential for newborns. Regular bathing, 2-3 times per week, using appropriate infant cleansing products is important for skin hygiene.
2. Ensure diapers are changed frequently and promptly.
Prolonged exposure of newborn skin to urine and feces can lead to skin breakdown, discomfort, irritation, and infection. Diapers should be changed as soon as the baby urinates or has a bowel movement. Avoid using perfumed baby wipes or wipes containing alcohol. Zinc-oxide based diaper creams can be used to treat and prevent diaper rash.
3. Educate parents on limiting the newborn’s exposure to direct sunlight.
Limit direct sun exposure to protect newborn skin, which is highly sensitive to UV radiation and prone to sunburn. When outdoors, use protective clothing and hats. Sunscreen use in infants under six months is generally not recommended without consulting a pediatrician due to safety concerns.
4. Advise against applying unnecessary skin care products to the newborn’s skin.
Newborn skin is highly absorbent and sensitive to topical agents. Avoid products containing perfumes and dyes that can cause irritation. For premature infants, whose skin may not retain moisture effectively, a thin layer of petroleum jelly can provide a protective barrier.
5. Instruct parents on when to seek professional medical advice for skin issues.
Most minor newborn skin conditions resolve with simple care measures. However, if skin problems persist, worsen, or show signs of infection (e.g., fever, drainage), parents should seek medical advice from a pediatrician.
Risk for Infection
Newborns are inherently at increased risk for infection due to their immature immune systems, which are not yet fully capable of defending against pathogens, especially in the first few months of life.
Nursing Diagnosis: Risk for Infection
Related Factors:
- Immature acquired immunity
- Deficiency in neutrophils and specific immunoglobulins
- Environmental exposure to pathogens
- Broken skin integrity
- Tissue trauma
- Reduced ciliary action in respiratory tract
As evidenced by:
A risk diagnosis is identified by the presence of risk factors, not by signs and symptoms, as the problem has not yet occurred. Nursing interventions are focused on prevention.
Expected Outcomes:
- Parents or caregivers will verbalize at least two infection prevention or risk reduction strategies.
- Parents or caregivers will demonstrate creating a protected environment for the newborn.
- The newborn will remain free from infection throughout the care period.
Assessment:
1. Identify and assess contributing risk factors for infection.
Risk factors include an immature immune system and any underlying health conditions. Newborns are more susceptible to infections due to lower levels of immunoglobulins (IgA, IgE, and IgD). Prematurity, congenital anomalies, and maternal factors like premature rupture of membranes (PROM) or birth trauma further elevate infection risk.
2. Evaluate the newborn’s immune status, considering both natural and acquired immunity.
Natural immunity is developed through antibody production following exposure to an infection, preventing recurrence of the same disease. Passive immunization (e.g., immunoglobulin administration) and active immunization (vaccination) are strategies to prevent certain communicable diseases.
3. Monitor for early signs and symptoms of infection.
Be vigilant for subtle indicators of infection in newborns, such as poor feeding, respiratory difficulties, fever, persistent crying, and unusual irritability.
Interventions:
1. Ensure strict adherence to infection control protocols and meticulous hand hygiene.
Hand washing is the most effective measure to prevent healthcare-associated infections. Healthcare providers must rigorously follow infection prevention practices, especially during direct care and invasive procedures, to protect newborns from infection.
2. Promote and support breastfeeding, if chosen by the mother.
Breast milk provides natural immunoglobulins that offer protection against various infections. Mothers who choose to breastfeed should be encouraged and supported to do so, given its immunological benefits for the newborn.
3. Screen caregivers and visitors for any signs of illness before they interact with the newborn.
To minimize exposure and transmission of pathogens, encourage individuals who are ill to avoid contact with newborns. If contact is unavoidable, caregivers or visitors should wear masks to reduce the risk of transmitting bacteria or viruses.
4. Provide comprehensive health education on infection control measures to parents and caregivers.
Educate parents and caregivers on consistently practicing effective infection control measures, including proper hand hygiene techniques. Advise limiting public outings during the newborn’s first few weeks of life to reduce exposure to pathogens. Recommend and educate about necessary vaccinations. Provide educational materials and offer practical demonstrations as needed to reinforce learning.
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.
