The newborn phase, spanning the first few months of life, is a period of remarkable adaptation as infants adjust to life outside the womb. From initiating respiration to mastering feeding, digestion, and elimination, newborns undergo rapid physiological changes. This period of rapid development continues throughout the first year, marked by significant physical milestones and engagement with the surrounding environment.
Key physical milestones during this time include:
- Consistent weight gain
- Maturation of eyesight
- Development of hearing
- Refinement of smell
- Expansion of taste perception
- Sensitivity of touch
- Integration of reflexes
- Progression of motor development
The first week of a newborn’s life is particularly vulnerable, with the majority of neonatal deaths occurring during this period. Common causes of newborn mortality include preterm birth, intrapartum-related complications such as birth asphyxia, infections, and congenital anomalies.
This article will delve into common nursing diagnoses relevant to newborn care, providing a framework for nurses to effectively assess, plan, and implement care.
The Nursing Process in Newborn Care
Nurses play a crucial role in the comprehensive assessment and monitoring of newborns. This begins immediately after birth with the Apgar score, a rapid evaluation of respiratory effort, heart rate, muscle tone, reflexes, and skin color. Subsequent assessments include measurements of length and weight, as well as necessary laboratory tests.
Beyond physical assessments, nurses are vital educators and support systems for new parents. They guide parents in essential newborn care practices such as feeding, bathing, and understanding infant cues, fostering confidence and competence in their new roles.
Common Nursing Care Plans for Newborns
Nursing care plans are essential tools for prioritizing assessments and interventions based on identified nursing diagnoses. They provide a structured approach to care, ensuring both short-term and long-term goals are addressed. Here are examples of common nursing care plans for newborns:
Imbalanced Nutrition: Less Than Body Requirements
Newborns are vulnerable to imbalanced nutrition for various reasons, ranging from insufficient breast milk intake to underlying health conditions. Factors such as inadequate breast milk supply, infections, environmental influences, genetic predispositions, neglect, and lack of parental knowledge can all contribute to this diagnosis.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related Factors:
- Insufficient breast milk intake
- Lack of knowledge regarding breast milk 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
- Inadequate increase in height for age and gender
- Insufficient 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 demonstrate a weight gain of at least 5 to 7 ounces per week for the first three months of life.
- The newborn will exhibit signs of adequate nutrition and hydration, indicated by 6-8 wet diapers daily, restful sleep patterns, and alertness during wakeful periods.
Assessments:
1. Evaluate the frequency and duration of breastfeeding sessions.
While formula feeding is a valid choice, newborns ideally should be fed 8-12 times per day during the first month. Breastfed infants typically feed every 2 to 4 hours, nursing for 10 to 15 minutes on each breast.
2. Assess the newborn’s feeding ability.
Newborns who are ill or premature have increased nutritional and energy demands. They may experience feeding difficulties due to immature digestive systems and challenges coordinating sucking, swallowing, and breathing.
3. Determine the parents’ understanding of infant feeding cues.
Educate parents to recognize early hunger cues such as lip smacking, tongue protrusion, rooting reflexes, and bringing fists to the mouth. Crying is often a late indicator of hunger.
Interventions:
1. Educate the mother on optimal breastfeeding positions and latch techniques.
Assess for any breastfeeding complications like mastitis or engorgement. Assist the mother in finding comfortable breastfeeding positions. Observe mother-infant latch to identify and correct any difficulties. Proper latch should be painless. The nipple should be positioned high and deep in the infant’s mouth, with a wide mouth opening and the lower lip turned outward against the breast. The infant’s chin should touch the breast, and the nose should be close. Audible sucking and swallowing sounds indicate effective feeding.
2. Monitor the newborn’s weight, growth, and developmental progress.
Newborns may initially lose up to 10% of their birth weight, typically regaining it within one to two weeks. Consistent weight gain of 5-7 ounces per week is expected until around four months of age, when the rate of weight gain may begin to slow.
3. Instruct on breast milk expression and storage if direct breastfeeding is not feasible.
Expressed breast milk provides essential nutrients and antibodies, offering a valuable alternative when direct breastfeeding is challenging.
4. Monitor the newborn’s hydration status and overall health.
Dehydration can further compromise newborn nutrition and well-being. Assess fontanelles, skin turgor, mucous membranes, and urine and stool output. Be alert to signs of lethargy and weakness, which may indicate inadequate nutrition.
5. Provide referrals to support resources as needed.
The Women, Infants, and Children (WIC) program is a federally funded program that offers nutritional support, including food, counseling, and breastfeeding assistance, to eligible low-income families.
Risk for Hypothermia
Newborns are at risk for hypothermia due to their large surface area relative to their volume. This ratio is even more pronounced in low-birth-weight infants, leading to rapid heat loss. The transition 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 in proportion to body mass
- Limited subcutaneous fat for insulation
- Limited reserves of brown fat for heat generation
- Sparse white fat reserves
- Thin epidermis, increasing heat loss susceptibility
- Inability to shiver as a thermoregulatory mechanism
- Infectious processes
- Impaired thermoregulation
- Environmental factors (cold room temperature)
- Cesarean delivery
As evidenced by:
Risk diagnoses are not evidenced by signs and symptoms, as the problem has not yet occurred. Interventions are preventative.
Expected Outcomes:
- The newborn will maintain body temperature within the normal range.
- Parents/caregivers will verbalize understanding of hypothermia and preventative measures.
Assessments:
1. Continuously monitor the newborn’s body temperature.
Accurate temperature measurement is essential for proper diagnosis and intervention. Rectal temperature measurement is generally considered the most accurate for newborns. Educate parents/caregivers on proper temperature measurement techniques. A temperature below 97.7°F (36.5°C) is considered below normal.
2. Identify and assess risk factors for hypothermia.
Prematurity, low birth weight, and conditions affecting thermoregulation such as sepsis or drug withdrawal increase hypothermia risk.
3. Observe for signs of cold stress.
Cold stress triggers metabolic and physiological imbalances. Newborns increase oxygen consumption and calorie expenditure in an attempt to generate heat. Prolonged cold stress can hinder growth and development.
Interventions:
1. Ensure the newborn is thoroughly dried and warmly wrapped in blankets.
Evaporation from wet skin leads to rapid heat loss. Prompt drying and swaddling are crucial.
2. Implement heat loss barriers.
Preterm and low-birth-weight infants require interventions to minimize heat loss. Use blankets, isolettes, and radiant warmers as needed. Encourage skin-to-skin contact with the mother, which has been shown to effectively reduce hypothermia risk.
3. Maintain a warm environment.
Newborns lack sufficient adipose tissue for insulation and cannot shiver effectively. They lose heat much faster than adults. Maintaining a warm room temperature is essential, even for healthy, full-term newborns.
4. Provide comprehensive education to parents/caregivers.
Educate parents about the risks of hypothermia and hyperthermia in newborns. Emphasize the importance of thermal protection. Demonstrate and supervise care activities like bathing and swaddling, ensuring hypothermia prevention is integrated into routine care.
Risk for Impaired Gas Exchange
Impaired gas exchange risk in newborns can arise from delayed adaptation to extrauterine life, congenital defects, or acquired conditions like lung infections that develop before or after birth.
Nursing Diagnosis: Risk for Impaired Gas Exchange
Related Factors:
- Reduced lung function and compliance
- Increased metabolic rate
- Tendency for decreased functional residual capacity (FRC)
- Increased airway resistance due to mucus production
- Cold stress
As evidenced by:
Risk diagnoses are not evidenced by signs and symptoms, as the problem has not yet occurred. Interventions are preventative.
Expected Outcomes:
- The newborn will maintain arterial blood gas (ABG) values within normal limits.
- The newborn will maintain oxygen saturation levels within the normal range.
- The newborn will exhibit no signs of nasal flaring or chest wall retractions.
Assessments:
1. Regularly assess the newborn’s respiratory status.
Respiratory assessment reflects the effectiveness of alveolar ventilation. Low PaO2 levels may indicate the need for respiratory support.
2. Monitor for signs of labored breathing.
Observe for nasal flaring, grunting, chest wall retractions, and cyanosis. These signs suggest increased oxygen demand and energy expenditure.
3. Review hemoglobin and arterial blood gas (ABG) test results.
ABG values are influenced by respiratory, circulatory, and metabolic processes. Hemoglobin levels reflect the blood’s oxygen-carrying capacity.
4. Assess the caregiver’s ability to recognize respiratory distress symptoms.
Parents/caregivers should be educated to recognize signs of respiratory distress in newborns, including tachypnea, nasal flaring, apnea, cyanosis, noisy breathing, grunting, and chest retractions.
Interventions:
1. Elevate the head of the newborn’s bed.
An upright or elevated position facilitates breathing by promoting optimal chest expansion. It also improves visualization for assessing respiratory distress.
2. Suction the airway as needed.
Newborns may be unable to clear airway secretions effectively. Suctioning may be necessary if mucus is audible or observed. Monitor pulse oximetry and vital signs to evaluate suctioning effectiveness.
3. Administer supplemental oxygen as prescribed.
Oxygen can be delivered via nasal cannula or face mask to support gas exchange.
4. Ensure availability of equipment for emergency ventilation.
Emergency ventilation equipment, including appropriately sized suction catheters and endotracheal/tracheostomy sets, should be readily accessible at the bedside.
Risk for Impaired Skin Integrity
Newborns are prone to skin problems such as diaper rash and cradle cap. Education on prevention and management of skin breakdown is crucial to minimize infection risk. Circumcision, while not a skin condition, also presents a risk for impaired skin integrity if not properly cared for post-procedure.
Nursing Diagnosis: Risk for Impaired Skin Integrity
Related Factors:
- Lack of caregiver knowledge regarding skin integrity maintenance
- Malnutrition
- Fluid and electrolyte imbalances
- Thermoregulation problems
- Exposure to moisture (urine, stool)
- Immunodeficiency
As evidenced by:
Risk diagnoses are not evidenced by signs and symptoms, as the problem has not yet occurred. Interventions are preventative.
Expected Outcomes:
- The newborn will maintain intact skin integrity with good skin turgor.
- Caregivers will verbalize understanding and demonstrate interventions to promote newborn skin health.
Assessments:
1. Assess the infant’s skin condition and characteristics.
Regular skin assessment helps identify early signs of potential skin problems, allowing for prompt intervention.
2. Evaluate the parent’s knowledge of newborn skin care practices.
Assessing parental knowledge helps determine their ability to prevent skin integrity issues and guides patient education strategies.
Interventions:
1. Recommend the use of gentle infant cleansers.
Maintain clean, dry newborn skin. Bathing 2-3 times per week is generally sufficient. Use mild, fragrance-free infant cleansers.
2. Change diapers frequently and promptly.
Prolonged exposure to urine and feces can lead to skin breakdown, irritation, and infection. Change diapers as soon as they are wet or soiled. Avoid wipes containing perfumes or alcohol. Zinc oxide-based diaper creams can be used to soothe redness.
3. Advise parents to limit newborn sun exposure.
Newborn skin is highly sensitive to UV radiation and burns easily. Minimize sun exposure and use protective clothing and hats when outdoors. Sunscreen is generally not recommended for infants under six months unless advised by a pediatrician.
4. Caution against applying unnecessary skin products to newborn skin.
Newborn skin is highly absorbent and sensitive. Avoid products with perfumes and dyes. For preterm infants, petroleum jelly may help protect and moisturize the skin.
5. Educate parents on when to seek professional medical advice.
Most minor newborn skin issues resolve with simple interventions. However, persistent or worsening conditions, or signs of infection (fever, drainage), require pediatrician consultation.
Risk for Infection and Nursing Diagnosis Circumcision Considerations
Newborns have an immature immune system, making them more susceptible to infections, particularly in the first few months of life. Procedures like circumcision, while common, introduce a potential site for infection if not properly managed. Therefore, Nursing Diagnosis Circumcision often intersects with Risk for Infection and requires specific care considerations.
Nursing Diagnosis: Risk for Infection
Related Factors:
- Immature immune system and inadequate acquired immunity
- Deficiency of neutrophils and specific immunoglobulins
- Environmental exposure to pathogens
- Disruption of skin integrity (including surgical sites like circumcision)
- Traumatized tissues
- Reduced ciliary action
As evidenced by:
Risk diagnoses are not evidenced by signs and symptoms, as the problem has not yet occurred. Interventions are preventative.
Expected Outcomes:
- Parents/caregivers will verbalize at least two infection prevention measures.
- Parents/caregivers will demonstrate creating a protected environment for the newborn.
- The newborn will remain free from infection.
Assessments:
1. Identify and assess contributing risk factors for infection.
Immature immune systems and underlying conditions increase infection risk. Newborns have lower levels of protective immunoglobulins (IgA, IgE, IgD). Prematurity, congenital defects, and maternal complications like PROM or delivery trauma further elevate risk.
2. Evaluate the newborn’s immune status.
Natural immunity develops through antibody production after infection. Passive immunization (immunoglobulin administration) and active immunization (vaccination) can prevent certain communicable diseases.
3. Monitor for signs and symptoms of infection.
Be alert for signs of infection such as poor feeding, respiratory difficulties, fever, excessive crying, and irritability.
Interventions:
1. Emphasize strict adherence to infection control and hand hygiene practices.
Handwashing is the most effective measure to prevent healthcare-associated infections. Nurses must strictly follow infection prevention protocols, especially during invasive procedures, to protect newborns.
2. Promote breastfeeding when possible.
Breast milk provides natural immunoglobulins that offer protection against preventable infections.
3. Screen caregivers and visitors for potential illnesses.
Advise individuals who are ill to avoid contact with newborns. Caregivers or visitors may wear masks to minimize transmission of pathogens.
4. Provide thorough health education on infection control measures, including post-circumcision care.
Educate parents and caregivers on hand hygiene and other infection control practices. For circumcised newborns, teach proper wound care to prevent infection. This includes gentle cleaning as directed by the pediatrician and observing for signs of infection at the circumcision site. Limit public outings during the initial weeks. Recommend and schedule necessary vaccinations. Provide educational materials and demonstrations as needed.
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.
