Neonatal Nursing Diagnosis

The first 28 days of life outside the womb are considered the neonatal period. This is a particularly vulnerable time in life, especially if the infant is born prematurely. Many things happen at birth, including the initiation of independent breathing, the beginning of temperature self-regulation and the commencement of breast or bottle feeding. Nursing care during this period must take these factors into account and plan accordingly. Nursing diagnoses are an integral part of developing care plans that guide nursing actions.

The Nursing Process

• Nursing diagnoses are an integral part of planning patient care. A nursing diagnosis is not the same as a medical diagnosis. Rather, it is a clinical judgment about patient responses to actual or potential health problems. A nursing diagnosis arises from the patient's health status and determines the care the nurse provides for the patient.

  There is typically more than one nursing diagnosis in a nursing care plan. For every nursing diagnosis, there must be a measurable goal toward which the nurse is working, as well as a list of steps she will take to reach the goal.

Neonatal Jaundice

• Neonatal, or newborn, jaundice is a common medical diagnosis. Medical treatment typically consists of phototherapy, or placing the infant under lights or in a special lighted bed.

  One possible nursing diagnosis related to neonatal jaundice is Risk for Fluid Volume Deficit Related to Phototherapy. This is because the lights can dehydrate the baby.

  A nursing goal for this diagnosis would be: The infant will not exhibit signs of dehydration and will display appropriate weight gain.

  Assessing for signs of dehydration would be an important nursing action for this diagnosis. To do this, the nurse would assess for poor skin turgor by gently pinching the skin to see if it "tented" or kept its shape, which would indicate dehydration. The nurse would also look for depressed fontanels, sunken eyes, decreased urine output, weight loss and assessing blood lab values for changes in electrolyte levels.

  If dehydration was present, the nurse would replace lost fluid. The expected outcome would be that the baby will have good skin turgor and six to eight wet diapers per day and will maintain weight.

  This is an example of a risk diagnosis, in which care is aimed at preventing a problem.

Substance-Abusing Mother

• One possible neonatal nursing diagnosis for a baby of a substance-abusing mother is Altered Nutrition, when the Baby Receives Less Than its Body Requires due to vomiting, diarrhea and an uncoordinated suck and swallow reflex because the baby is going through drug withdrawal.

  Note that there are two problem areas: Vomiting and diarrhea and uncoordinated suck and swallow reflex, both of which can make it hard for the baby to get enough nutrition.

  The goal: The infant will gain or maintain weight.

  Nursing interventions include: Assessing sucking and swallowing reflexes; using a bulb syringe to clear nose if infant has trouble breathing due to congestion and is therefore having trouble eating; position infant on right side after feedings to prevent vomiting.

  Expected outcomes would include tolerating feedings, maintain weight or gain weight as evidenced by no vomiting or inhaling of milk into lungs during feedings.

Wellness Diagnosis for the Newborn

• Nursing diagnoses can also focus on positive developments. One example of these in the neonate is Readiness for Enhanced Organized Infant Behavior Due to Prematurity.

  Some goals could be: Infant will display stable vital signs and skin color; infant will display smooth transitions between sleep and wake states; infant will display pleasure with sensory-motor experiences.

  Nursing actions to help bring this about could include: Teach parents ways to facilitate motor organization and development by appropriate handling techniques.

Parents

• Parental knowledge, or lack thereof, can have a profound effect upon the health of the newborn, particularly if the newborn is considered high risk due to prematurity or other health issues. One example of a possible nursing diagnosis aimed at the parents but that would affect the neonate would be: Ineffective therapeutic regimen management related to complexity of therapeutic regimen.

  The nursing plan would be aimed at educating the parents regarding specific care behaviors they needed to learn to be able to adequately care for their newborn.