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Ineffective Thermoregulation related to Asphyxia Neonatorum
Nursing Care Plan for Asphyxia NeonatorumNeonatal asphyxia is a condition in newborns who fail to breathe spontaneously and regularly soon after birth.
Signs and Symptoms
- Hypoxia.
- Respiration rate of more than 60 x / min or less than 30 x / min.
- Gasping breath until respiratory arrest may occur.
- Bradycardia.
- The reduced muscle tone.
- Cyanotic skin color / pale.
- Blood Gas Analysis.
- Blood electrolytes.
- Blood sugar.
- Baby grams (chest X-ray).
- Ultrasound (head).
Nursing Diagnosis :
Ineffective thermoregulation related to temperature regulation system is not inadequate.
Nursing Outcomes :
Thermoregulation: neonate
Indicators:
Normal body temperature
Assessment scale:
1. Extremely compromised.
2. Substantially compromised.
3. Moderately compromised.
4. Mildly compromised.
5. Not compromised.
Nursing Interventions
Temperature regulation
- Place the baby in a warm temperature environments.
- Monitor axillary temperature in infants unstable.
- Monitor signs of hypothermia: fatigue, weakness, discoloration, skin.
- Avoid situations that may cause the baby to lose heat, such as exposure to cold air, window or shower.
Rationale :
- Maintaining the temperature of the baby's body.
- Monitor the baby's body temperature.
- Avoiding heat loss through conduction.
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