Ineffective Thermoregulation related to Asphyxia Neonatorum

Nursing Care Plan for Asphyxia Neonatorum

Neonatal asphyxia is a condition in newborns who fail to breathe spontaneously and regularly soon after birth.

Signs and Symptoms

1. Hypoxia.
2. Respiration rate of more than 60 x / min or less than 30 x / min.
3. Gasping breath until respiratory arrest may occur.
4. Bradycardia.
5. The reduced muscle tone.
6. Cyanotic skin color / pale.

Diagnostic examination

1. Blood Gas Analysis.
2. Blood electrolytes.
3. Blood sugar.
4. Baby grams (chest X-ray).
5. 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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Ineffective Airway Clearance related to Asphyxia Neonatorum

Nursing Diagnosis :

Nursing Interventions : Ineffective airway clearance related to obstruction of mucus.

Nursing Outcomes:

Repiration status: Ventilation
Indicators:

• Free of abnormal breath sounds.
• No shortness of breath.
• Respiration rate is within the normal range.
• Regular respiratory rhythm.
• No retraction of the chest.

Assessment scale:

1. Extremely compromised.
2. Substantially compromised.
3. Moderately compromised.
4. Mildly compromised.
5. Not compromised.

Nursing Interventions

Airway management

• Open the airway.
• Position the patient to maximize ventilation.
• Identification of patients need artificial airway appliance installation.
• Remove secretions by suction.
• Auscultation of breath sounds, note the presence of additional noise.
• Set intake to optimize fluid balance.
• Monitor respiration and O2 status every 6 hours.

Vital sign monitoring

• Monitor blood pressure, pulse, temperature, and respiration.
• Monitor quantities and heart rhythm.
• Monitors heart sounds.
• Monitor lung sounds.
• Monitor abnormal breathing patterns.
• Monitor temperature, color, and moisture.
• Monitor peripheral cyanosis.
• Identify the causes of changes in vital signs.

Oxygen therapy

• Setting up the oxygen equipment and a humidifier.
• Provide supplemental oxygen by order.
• Monitor the liter flow of oxygen.
• Monitoring canule position.
• Monitor signs of oxygen toxicity.

Rationale:

• Patency of the airway is the main requirement to obtain adequate ventilation.
• Helping lungs to meet the body's need for oxygen.
• Assessing changes in status, to determine actions to improve / maintain the status respiration.

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