The newborn phase, encompassing the first few months of life, is a period of critical adaptation as infants transition to life outside the womb. This period, especially the first week, is particularly vulnerable, with a high percentage of neonatal deaths occurring during this time, often linked to complications such as preterm birth. Nurses play a pivotal role in assessing and supporting newborns, especially those born prematurely, ensuring their healthy development through meticulous care and early intervention.
The Nurse’s Role in Newborn Assessment and Care
Nurses are at the forefront of newborn care, conducting thorough assessments to monitor the neonate’s adaptation to extrauterine life. This begins immediately after birth with the Apgar score, evaluating vital signs like respiratory effort, heart rate, muscle tone, reflexes, and skin color. Subsequent assessments include monitoring weight, length, and relevant lab tests.
Beyond physical assessments, nurses are 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. For premature infants, this educational and supportive role is even more critical due to the increased complexities of their care.
Nursing Care Plans for Newborns: Addressing Key Diagnoses
Nursing care plans are essential tools for organizing and prioritizing care for newborns. These plans are built upon identified nursing diagnoses, guiding assessments and interventions to achieve both short-term and long-term health goals. While many diagnoses apply to all newborns, certain conditions are more prevalent or have unique considerations in premature infants. Here are common nursing diagnoses in newborns, with a particular emphasis on aspects relevant to premature babies:
Imbalanced Nutrition: Less Than Body Requirements
Newborns, especially premature infants, are at risk for imbalanced nutrition due to various factors. Premature babies often have underdeveloped digestive systems, weaker sucking reflexes, and increased nutritional needs to support rapid growth and development. Inadequate breast milk intake, ineffective breastfeeding, underlying health conditions, and prematurity itself are significant contributing factors.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related to:
- Inadequate breast milk intake
- Inadequate knowledge of infant feeding requirements
- Inadequate breast milk production
- Ineffective breastfeeding
- Interrupted breastfeeding
- Underlying health condition
- Prematurity
As evidenced by:
- Body weight below ideal range for age and gender
- Inadequate height and head circumference growth
- Neonatal weight loss or poor weight gain
- Constipation or poor stool output
- Pale mucous membranes
- Lethargy
- Muscle hypotonia
Expected outcomes:
- Newborn will gain at least 5 to 7 ounces per week for the first three months.
- Newborn will demonstrate adequate hydration and nutrition, indicated by 6-8 wet diapers daily, restful sleep, and alertness.
Assessment:
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Assess breastfeeding frequency and duration: Newborns should feed 8-12 times in 24 hours in the first month. Breastfed infants typically feed every 2-4 hours, nursing for 10-15 minutes per breast. Premature infants may tire easily and require more frequent, shorter feedings.
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Assess newborn feeding ability: Premature and sick newborns may have difficulty coordinating sucking, swallowing, and breathing, impacting their ability to feed effectively by mouth. Their nutritional and energy demands are also higher.
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Assess parental knowledge of feeding cues: Educate parents on hunger cues like lip smacking, tongue protrusion, rooting, and hand-to-mouth movements. Crying is a late sign of hunger. For premature infants, these cues may be subtle or absent, requiring nurses to guide parents in recognizing early hunger signs or feeding based on a schedule.
Interventions:
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Instruct on breastfeeding positions and latching: Assist mothers with comfortable breastfeeding positions and assess for latch difficulties. Proper latch is crucial for effective milk transfer and preventing nipple pain. For premature infants, alternative feeding methods like paced bottle-feeding with breast milk may be necessary initially.
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Monitor weight, growth, and development: Newborns may lose up to 10% of birth weight initially but should regain it within two weeks. Consistent weight gain is a key indicator of adequate nutrition. Premature infants require close monitoring of growth parameters, often needing specialized growth charts.
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Educate on breast milk expression and storage: If direct breastfeeding is challenging, pumping and bottle-feeding breast milk ensures the infant receives its benefits. This is particularly important for premature infants, as breast milk provides crucial antibodies and nutrients.
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Monitor hydration and overall health status: Dehydration can exacerbate nutritional imbalances. Assess fontanelles, skin turgor, mucous membranes, and urine/stool output. Lethargy and weakness can signal inadequate nutrition and require prompt intervention.
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Offer resources: Programs like Women, Infants, and Children (WIC) provide nutritional support and breastfeeding assistance for eligible families. For premature infants, specialized follow-up clinics and support groups can be invaluable.
Risk for Hypothermia
Newborns, especially premature infants, are highly susceptible to hypothermia due to their large surface area to body volume ratio, limited subcutaneous fat, and immature thermoregulation. Premature babies have even less brown fat (used for heat production) and thinner skin, increasing heat loss. The transition from the warm uterus to a cooler environment poses a significant risk.
Nursing Diagnosis: Risk for Hypothermia
Related to:
- Large surface area compared to mass
- Inadequate insulating subcutaneous fat
- Exhaustible brown fat sources
- Few white fat reserves
- Thin epidermis susceptible to increased heat loss
- Inability to shiver
- Infectious process
- Impaired thermoregulation
- Environmental concerns
- Prematurity
- Cesarean delivery
As evidenced by:
- Risk diagnoses are not evidenced by signs and symptoms. Interventions focus on prevention.
Expected outcomes:
- Newborn will maintain body temperature within normal limits (97.7°F – 99.5°F or 36.5°C – 37.5°C).
- Parents/caregivers will verbalize understanding of hypothermia and preventive measures.
Assessment:
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Monitor body temperature: Rectal temperature is the most accurate for newborns. Educate parents on proper temperature measurement. Hypothermia is defined as a temperature below 97.7°F (36.5°C). Premature infants require continuous temperature monitoring in incubators or radiant warmers.
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Assess risk factors: Prematurity, low birth weight, sepsis, and drug withdrawal increase hypothermia risk.
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Monitor for cold stress: Cold stress occurs when a newborn expends excessive energy to generate heat, leading to increased oxygen and calorie consumption. Prolonged cold stress can impair growth and lead to serious metabolic and physiological problems. Premature infants are particularly vulnerable to cold stress.
Interventions:
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Keep newborn dry and swaddled: Dry the newborn immediately after birth and bath and swaddle in warm blankets to minimize heat loss, especially crucial for premature infants.
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Provide heat loss barriers: Utilize blankets, incubators, and radiant warmers to maintain a warm environment. Skin-to-skin contact with the mother is highly effective for temperature regulation. Premature infants often require incubators with controlled humidity and temperature.
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Provide a warm environment: Newborns cannot effectively regulate their body temperature and lose heat much faster than adults. Maintain a warm room temperature.
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Educate parents/caregivers: Teach parents about hypothermia and hyperthermia risks, emphasizing thermal protection. Demonstrate and supervise bathing and swaddling techniques. For parents of premature infants, educate on the specific temperature control needs and monitoring at home.
Risk for Impaired Gas Exchange
Impaired gas exchange in newborns can result from delayed adaptation to extrauterine life, congenital defects, or acquired conditions like lung infections. Premature infants are at significantly higher risk due to immature lung development and surfactant deficiency, leading to conditions like respiratory distress syndrome (RDS).
Nursing Diagnosis: Risk for Impaired Gas Exchange
Related to:
- Low lung function and compliance
- Significant increased metabolic rate
- Reduced functional residual capacity (FRC)
- Increased mucus production
- Cold stress
- Prematurity
As evidenced by:
- Risk diagnoses are not evidenced by signs and symptoms. Interventions focus on prevention.
Expected outcomes:
- Newborn will maintain arterial blood gases (ABGs) within normal limits.
- Newborn will maintain oxygen saturation within normal limits (typically >95%).
- Newborn will exhibit absence of nasal flaring and chest wall retractions.
Assessment:
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Assess respiratory status: Monitor respiratory rate, depth, and effort. Low PaO2 levels may indicate the need for respiratory support. Premature infants may require continuous respiratory monitoring and pulse oximetry.
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Note signs of labored breathing: Observe for nasal flaring, grunting, chest retractions, and cyanosis, which indicate increased oxygen demand.
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Review hemoglobin and ABG results: ABGs reflect respiratory, circulatory, and metabolic status. Hemoglobin levels indicate oxygen-carrying capacity.
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Assess caregiver knowledge of respiratory distress symptoms: Educate parents on recognizing signs of respiratory distress in newborns, including tachypnea, nasal flaring, apnea, cyanosis, noisy breathing, grunting, and chest retractions. This is particularly important for parents of premature infants who are at higher risk for respiratory complications even after discharge.
Interventions:
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Elevate head of bed: Promotes chest expansion and easier breathing.
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Suction airway as needed: Newborns may not clear secretions effectively. Suctioning may be necessary if mucus is present. Monitor pulse oximetry and vital signs during and after suctioning.
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Administer oxygen: Oxygen therapy via nasal cannula or face mask may be required to improve gas exchange. Premature infants with RDS may require more advanced respiratory support like CPAP or mechanical ventilation.
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Prepare for emergency ventilation: Ensure emergency ventilation equipment is readily available, including appropriate-sized suction catheters and ET/tracheostomy sets for infants.
Risk for Impaired Skin Integrity
Newborn skin is delicate and susceptible to breakdown. While diaper rash and cradle cap are common in all newborns, premature infants have even more fragile skin due to their underdeveloped epidermal barrier, making them highly vulnerable to skin damage from friction, moisture, and adhesive products.
Nursing Diagnosis: Risk for Impaired Skin Integrity
Related to:
- Inadequate caregiver knowledge of skin integrity maintenance
- Malnutrition
- Fluid and electrolyte imbalance
- Thermoregulation problems
- Moisture (e.g., diaper area)
- Immunodeficiency
- Prematurity
As evidenced by:
- Risk diagnoses are not evidenced by signs and symptoms. Interventions focus on prevention.
Expected outcomes:
- Newborn will maintain intact skin with adequate turgor.
- Caregiver will verbalize understanding and demonstrate skin health promotion interventions.
Assessment:
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Assess skin characteristics and condition: Regular skin assessment helps identify potential problems early and allows for prompt intervention. Pay close attention to areas prone to breakdown, especially in premature infants who may be exposed to more medical devices and procedures.
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Assess parental knowledge of newborn skin care: Determine caregiver understanding of proper skin care practices to tailor education and prevent skin integrity issues.
Interventions:
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Encourage appropriate infant cleansers: Use mild, fragrance-free cleansers. Newborns only require bathing 2-3 times per week. For premature infants, gentle, water-based cleansers are preferred, and bathing frequency may be even less.
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Change diapers frequently: Prompt diaper changes prevent skin breakdown from urine and feces exposure. Use soft, fragrance-free wipes and consider zinc oxide creams for redness.
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Limit sun exposure: Newborn skin is highly sensitive to UV rays. Limit direct sun exposure and use protective clothing and hats. Sunscreen is generally not recommended for infants under six months.
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Avoid unnecessary skin products: Newborn skin is highly absorbent. Avoid perfumes and dyes that can irritate. For premature infants with very dry skin, a thin layer of petroleum jelly can provide a protective barrier.
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Instruct on when to seek assistance: Advise parents to contact a pediatrician if skin conditions persist, worsen, or show signs of infection.
Risk for Infection
Newborns have immature immune systems, making them more susceptible to infections, especially in the first few months of life. Premature infants are at even greater risk due to underdeveloped immune systems, decreased passive immunity from the mother, and often prolonged hospital stays with increased exposure to pathogens.
Nursing Diagnosis: Risk for Infection
Related to:
- Inadequate acquired immunity
- Deficiency of neutrophils and specific immunoglobulins
- Environmental exposure
- Broken skin (invasive procedures)
- Traumatized tissues
- Decreased ciliary action
- Prematurity
As evidenced by:
- Risk diagnoses are not evidenced by signs and symptoms. Interventions focus on prevention.
Expected outcomes:
- Parents/caregivers will verbalize two infection prevention measures.
- Parents/caregivers will demonstrate a protected environment for the newborn.
- Newborn will remain free from infection.
Assessment:
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Assess contributing factors: Identify risk factors such as prematurity, immature immune system, congenital defects, maternal complications (PROM), and invasive procedures.
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Assess immunity status: Understand the newborn’s level of passive immunity from the mother and any received immunizations.
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Monitor for infection symptoms: Observe for signs of infection like poor feeding, respiratory distress, fever (or temperature instability in premature infants), prolonged crying, and irritability. Subtle signs of infection should be carefully monitored in premature infants.
Interventions:
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Ensure strict infection control and hand hygiene: Meticulous handwashing is crucial. Adhere to infection control protocols, especially during invasive procedures.
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Encourage breastfeeding: Breast milk provides essential immunoglobulins that protect against infections.
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Monitor caregivers and visitors for illness: Limit newborn exposure to sick individuals. Encourage sick visitors to wear masks.
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Provide health teaching on infection control: Educate parents on hand hygiene, limiting public outings, and recommended vaccinations. For parents of premature infants, emphasize the importance of minimizing exposure to crowds and maintaining a clean home environment.
Conclusion
Nursing care for newborns, particularly premature infants, demands a comprehensive and proactive approach. Early recognition of potential health risks through careful assessment and accurate nursing diagnoses is paramount. By implementing well-structured nursing care plans focused on nutrition, thermoregulation, respiratory function, skin integrity, and infection prevention, nurses can significantly contribute to the healthy development and well-being of these vulnerable infants, empowering parents and ensuring a strong start to life.
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.
