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NCP Newborn Los Angeles Valley College

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					    ADMISSION DATE _________               ADULT LABORATORY/ DIAGNOSTIC TOOL      SOURCE:______________________
    Test        Range                       Date    Date    Date    Identify   WNL Significance/ Trends
                                            Baseline
C   WBC                5,000-10,000/
B                      mm3
C   RBCs               4.2-6.1
                        x 106/g
    Hgb                11.5-17.5
                       g/dl
    Hct                40-52%

    MCV                90-95
                       mm3
    MCH                27-31 g

    MCHC               32-36 g/dl

    RDW                11%-14.5%

    Retic.             0.5%-3.1%

    Platelet           150,000-
                       400,000 mm3
W   Neutrophils        55-70%
B
C   Lymphocytes        20-40%

D   Monocytes          2-8%
i
f
    Eosinophils        1-4%
f

    Basophils          0.5-1.0%

    Sodium             135-145 mEq/L
L
y
    Chloride           98-106
t
e                       mEq/L
s   Potassium          3.5-5.0
                       mEq/L
    CO2                24-30
                       mEq/L
    Magnesium          1.3-2.1
                       mEq/L
    Calcium            9.0-10.5
                       mg/dl
C
o
    INR                See lab result
a
g   PT                 11-12.5
                       seconds
    PTT                60-70 seconds
    On anticoag.      1.5-2.5 x control
R   BUN                10-20 mg/dl
e
n   Creatinine         0.5-1.2 mg/dl
a
l
    Test              Range                Date      Date        Date      Identify   WNL Significance/ Trends
             Note: Normal value range will vary depending on laboratory used.
                                           Baseline
    Glucose            70-110 mg/dl
B   W:NEWBORNCAREPLAN:1/06                                  -1-
l
o
Hgb A1c            4.4-6.4%

AST                0-35 U/L

ALT                4-36 IU/L

Acid               0.13-0.63 U/L
Phosphatase

Ammonia            80-110 g/dl

LDH                100-190 U/L

Amylase            30-220 U/L

Lipase             0-160 U/L

Phosphorus         3-4.5 mg/dl

Alk. Phos.         30-120 U/L

Total Bilirubin    .3-1.0 mg/dl

Cholesterol        <200 mg/dl

Uric acid          2.7-8.5 mg/dl

Total protein      6.4-8.3 g/dl

Albumin            3.5-5.0 g/dl

Globulin           2.3-3.4 g/dl

Digoxin level      0.8- 2.0 ng/ml

Theophylline       10-20 g/ml
level

Dilantin level     10-20 g/ml



Urinalysis                            Diagnostic Tests          ABGS
Date/Result                       Date/Results                  Date/Results             Date/Results
Color                             X-rays                        pH                       pH
Appearance                                                      pCO2                     pCO2
Spec. gravity                                                   pO2                      PO2
Protein                           Nuclear scans                 B.E                      B.E.
Glucose                                                         O2 sat                   O2 sat
Ketones                           CT/MRI                        Bicarb___________        Bicarb___________
Bacteria_________________________                               Comments_______________________________
Blood________________________ Other                                      ________________________________
Other___________________________________________________________         ________________________________
            Note: Normal value range will vary depending on laboratory used.




W:NEWBORNCAREPLAN:1/06                                    -2-
ADMISSION DATE _________      LABORATORY/ DIAGNOSTIC TOOL         SOURCE:______________________
Test        Range          Date     Date     Date    Identify   WNL Significance/ Trends
                           Baseline




W:NEWBORNCAREPLAN:1/06                    -3-
   ADMISSION DATE _________      LABORATORY/ DIAGNOSTIC TOOL         SOURCE:______________________
Test         Range          Date     Date    Date    Identify   WNL Significance/ Trends
                            Baseline




W:NEWBORNCAREPLAN:1/06                     -4-
   NURSING DIAGNOSES (NANDA, 2005-2006) GROUPED ACCORDING TO CONCEPTUAL FRAMEWORK
Oxygen Needs/Circulation                         Incontinence, Urge                                Community Coping, Ineffective
Breathing                                        Tissue Perfusion, Ineffective                     Community Coping, Readiness for Enhanced
Airway Clearance, Ineffective                    Urinary Elimination, Impaired                     Delayed Development, Risk for
Aspiration, Risk for                             Urinary Elimination, Readiness for Enhanced       Family Coping: Compromised, Ineffective
Breathing Pattern, Ineffective                   Urinary Retention                                 Family Coping: Disabled
Gas Exchange, Impaired                           Rest/Activity                                     Family Coping: Readiness for Enhanced
Infection, Risk for                              Activity Intolerance                              Family Processes, Dysfunctional:
Sudden Infant Death Syndrome, Risk for           Activity Intolerance, Risk for                        Alcoholism
Suffocation, Risk for                            Disuse Syndrome, Risk for                         Family Processes, Interrupted
Ventilation, Impaired, Spontaneous               Diversional Activity Deficient                    Family Processes, Readiness for Enhanced
Ventilatory Weaning                              Fatigue                                           Growth and Development, Delayed
    Response, Dysfunctional                      Mobility, Impaired Bed                            Loneliness, Risk for
Circulation                                      Mobility, Impaired Physical                       Parental Role Conflict
Cardiac Output, Decreased                        Mobility, Impaired Wheelchair                     Parent/Infant/Child Attachment,
Fluid Balance, Readiness for Enhanced            Perioperative Positioning Injury, Risk for            Impaired, Risk for
Fluid Volume Deficit                             Sedentary Lifestyle                               Parenting, Impaired
Fluid Volume Excess                              Sleep Deprivation                                 Parenting, Impaired, Risk for
Fluid Volume, Risk for Deficit                   Sleep Pattern, Disturbed                          Parenting, Readiness for Enhanced
Fluid Volume, Risk for Imbalanced                Sleep, Readiness for Enhanced                     Role Performance, Ineffective
Tissue Perfusion, Ineffective                    Transfer Ability, Impaired                        Social Interaction, Impaired
(specify: renal, cerebral,                       Walking, Impaired                                 Social Isolation
cardiopulmonary, gastrointestinal, peripheral)   Comfort/Sexuality                                 Violence, Risk for
Neurological/Neurovascular                       Comfort                                           Anxiety Concerns/Fear/Knowledge Needs
Neurological                                     Pain, Acute                                       Self-Esteem
Confusion, Acute                                 Pain, Chronic                                     Adjustment, Impaired
Confusion, Chronic                               Sexuality                                         Anxiety
Environmental Interpretation Syndrome,           Sexuality Pattern, Ineffective                    Body Image Disturbed
    Impaired                                     Sexual Dysfunction                                Coping, Defensive
Infant Behavior, Disorganized                    Safety/Skins/Wounds/Infections/Sensory            Coping, Ineffective
Infant Behavior, Readiness for                   Temperature                                       Coping, Readiness for Enhanced
    Enhanced Organized                           Hyperthermia                                      Death Anxiety
Infant Behavior, Risk for Disorganized           Hypothermia                                       Decisional Conflict (Specify)
Intracranial, Decreased Adaptive                 Temperature, Risk for Imbalanced Body             Denial, Ineffective
    Capacity                                     Thermoregulation, Ineffective                     Fear
Memory, Impaired                                 Skin                                              Grieving, Anticipatory
Thought Processes, Disturbed                     Infection, Risk for                               Grieving, Dysfunctional
Neurovascular                                    Injury, Risk for                                  Grieving, Dysfunctional, Risk for
Dysreflexia, Autonomic                           Latex Allergy Response                            Hopelessness
Dysreflexia, Risk for Autonomic                  Latex Allergy Response, Risk for                  Personal Identity, Disturbed
Peripheral Neurovascular Dysfunction,            Protection, Ineffective                           Post-Trauma Syndrome
    Risk for                                     Skin Integrity, Impaired                          Post-Trauma Syndrome, Risk for
Nutrition/Hydration                              Skin Integrity, Impaired, Risk for                Powerlessness
Breastfeeding, Effective                         Tissue Integrity, Impaired                        Powerlessness, Risk for
Breastfeeding, Ineffective                       Physical                                          Rape-Trauma Syndrome
Breastfeeding, Interrupted                       Falls, Risk for                                   Rape-Trauma Syndrome, Compound Reaction
Dentition, Impaired                              Growth, Risk for Disproportional                  Rape-Trauma Syndrome, Silent Reaction
Failure to Thrive, Adult                         Mobility, Impaired Physical                       Religiosity, Impaired
Fluid Volume, Deficit                            Perioperative Positioning Injury, Risk for        Religiosity, Readiness for Enhanced
Fluid Volume, Deficit, Risk for                  Trauma, Risk for                                  Religiosity, Risk for Impaired
Infant Feeding Pattern, Ineffective              Self-Care Deficit, Bathing/Hygiene                Relocation Stress Syndrome
Nausea                                           Self-Care Deficit, Dressing/Grooming              Relocation Stress Syndrome, Risk for
Nutrition: Imbalanced, Risk for                  Self-Care Deficit, Toileting                      Self-Esteem, Chronic Low
    More Than Body Requirements                  Surgical Recovery, Delayed                        Self-Esteem, Situational Low
Nutrition: Imbalanced, Less                      Wandering                                         Self-Esteem, Situational Low, Risk for
    Than Body Requirements                       Perception                                        Self-Mutilation
Nutrition: Imbalanced, More                      Energy Field, Disturbed                           Self-Mutilation, Risk for
    Than Body Requirements                       Environmental Interpretation Syndrome, Impaired   Sorrow, Chronic
Nutrition: Readiness for Enhanced                Infant Behavior, Disorganized                     Spiritual Distress
Oral Mucous Membranes, Impaired                  Infant Behavior, Disorganized, Risk for           Spiritual Distress, Risk for
Self-Care Deficit, Feeding                       Infant Behavior, Readiness for                    Spiritual Well-Being, Readiness for Enhanced
Swallowing, Impaired                                 Enhanced Organized                            Self-Actualization
Elimination                                      Poisoning, Risk for                               Health Maintenance, Ineffective
Bowel                                            Self-Mutilation                                   Health Seeking Behaviors (Specify)
Constipation                                     Self-Mutilation, Risk for                         Home Maintenance, Impaired
Constipation, Perceived                          Sensory/Perception, Disturbed (specify):          Knowledge, Deficient (Specify)
Constipation, Risk for                               Visual, Kinesthetic, Auditory,                Knowledge, Readiness for Enhanced (Specify)
Diarrhea                                             Gustatory, Tactile, Olfactory                 Noncompliance
Incontinence, Bowel                              Suicide, Risk for                                 Therapeutic Regimen: Community, Ineffective
Nausea                                           Unilateral Neglect                                    Management of
Urinary                                          Violence, Risk for Other-Directed                 Therapeutic Regimen: Families, Ineffective
Fluid Volume, Risk for Imbalanced                Violence, Risk for Self-Directed                      Management of
Infection, Risk for                              Love/Belonging/Culture/Coping/Body Image          Therapeutic Regimen: Management, Effective
Incontinence, Functional                         Adjustment, Impaired                              Therapeutic Regimen: Management, Ineffective
Incontinence, Reflex                             Caregiver Role Strain                             Therapeutic Regimen: Management,
Incontinence, Risk for Urge                      Caregiver Role Strain, Risk for                       Readiness for Enhanced
Incontinence, Stress                             Communication, Impaired Verbal
Incontinence, Total                              Communication, Readiness for Enhanced



W:NEWBORNCAREPLAN:1/06                                           -5-
Nursing 111 Physical Assessment: Newborn                                                     *Include all dates/times of care provided.
GENERAL APPEARANCE                           DATE/TIME INITIAL ASSESSMENT                    Date/Time*             Related Nursing Diagnoses
                                                                                             Explanation of         (Circle appropriate diagnoses)
                                                                                             Abnormal
                                                                                             Assessment Factors
Date/Time of Birth: ____________________ Apgar Score: 1 min _____ 5 min _____:
Thin, Emaciated, Well-developed, Well-nourished, No Acute Distress (NAD)                                            Latex Allergy Response
Height ________ Admitting Weight _____________Current Weight                                                        Latex Allergy Response,
Admitting Vital Signs                                                                                                  Risk for

I. PHYSIOLOGIC ASSESSMENT
    A.     OXYGENATION
           1.     BREATHING                                                                                         Airway Clearance, Ineffective
                                                                                                                    Aspiration, Risk for
Respiratory Rate __________         Rhythm:       Regular     Irregular                                           Breathing Pattern, Ineffective
                                    Depth:        Deep        Shallow                                             Gas Exchange, Impaired
                No distress        Grunting                 Apneic ___ sec.                                      Infection, Risk for
                Nasal flaring      Retractions              Tachypneic                                           Suffocation, Risk for
                                                                                                                    Ventilation, Impaired,
                See-saw Respirations
                                                                                                                       Spontaneous
                                                     BREATH SOUNDS
                                                     Cl - Clear
                                                     Cr - Crackles
                                                     Wh - Wheezing
                                                     D - Decreased
                                                     A - Absent
Oxygen Therapy:
O2 Saturation:         N/A     q ___ hr     Continuous Pulse Oximeter

Pulse Oximetry Readings (Identify on R.A. or O2): _______; _______; _______
Chest Config:          Symmetrical         Asymmetrical Circumference
                       2-3 cm less than head circumference
Nose:      Patent                Septum intact

           2.     CIRCULATION                                                                                       Cardiac Output, Decreased
                                                                                                                    Fluid Balance, Readiness for
Heart Rate                                   Rhythm                                                                    Enhanced
Heart Sounds: Describe                                                                                              Fluid Volume Deficit
Arterial                                                              D – Doppler                                   Fluid Volume, Deficit, Risk for
                   C     B      R     F       PT         DP
                                                                      A – Absent                                    Fluid Volume Excess
Pulses
                                                                      1+ - Barely Palpable                          Fluid Volume, Risk for
                                                                      2+ - Weak                                        Imbalanced
Right/                                                                3+ - Normal
                                                                                                                    Tissue Perfusion, Ineffective
                                                                      4+ - Full Bounding
Left                                                                                                                   (specify: renal, cerebral,
                                                                                                                       cardiopulmonary,
Capillary Refill:       Brisk <3 sec.      Prolonged >3 sec. _________ sec.                                          gastrointestinal, peripheral)
Edema:            Location
None       Generalized        Non-pitting       Pitting 1 + 2 + 3 + 4 + (circle)
Other
Skin Color:       Pink       Harlequin     Mottled     Plethora      Pallor
                  Jaundice      Acrocyanosis       Circumoral cyanosis
                  Cyanosis when crying




                                                                        -6-
            3.   NEUROLOGICAL                                               Date/Time            Related Nursing Diagnoses
                                                                            Explanation of       (Circle appropriate diagnoses)
                                                                            Abnormal
                                                                            Assessment Factors
Level Of Consciousness: Awake            Alert    Drowsy     Asleep                          Environmental Interpretation
                                                                                                    Syndrome, Impaired
Response to Stimuli
                                                                                                 Infant Behavior, Disorganized
Cry:         Strong     Weak       High-pitched     Cat-like                                 Infant Behavior, Readiness for
                                                                                                    Enhanced Organized
Ears:        Low-set       At or above outer eye canthus    Skin tags                         Infant Behavior, Risk for
             Responds to sound          Preauricular dimples/sinuses                              Disorganized
                                                                                                 Intracranial, Decreased Adaptive
Eyes:      PERRL Pinpoint          Gazes at object                                               Capacity
           Follows object                                                                       Memory, Impaired
           Subconjunctival hemorrhage Strabismus            Nystgmus                          Thought Processes, Disturbed
           Ptosis Conjunctivitis Sclera white
Describe

Head: Circumference: __________             2-3 cm > Chest Circumference
Molding         Overriding sutures     Caput succedaneum
Cephalhematoma          Head/neck moves freely       Torticollis

Fontanels:       Flat      Depressed      Bulging    Sutures palpable

Muscle tone: WNL            Flexed     Hypo     Hyper
                 Flaccid      Rigid     Jittery/tremors
Seizures        Describe

Reflexes:         Moro       Babinski’s
                  Palmar
Abnormal


            4.   NEUROVASCULAR                                                                   Dysreflexia, Autonomic
                                                                                                 Dysreflexia, Risk for
Extremities Examined:                                                                               Autonomic
Color:          Pink Reddened Blue Blanched                                                  Peripheral Neurovascular
Temperature:    Cool Warm Hot                                                                    Dysfunction, Risk for
Movement:       Active Passive Symmetrical Asymmetrical




                                                                      -7-
B. NUTRITION                                                                 Date/Time             Related Nursing Diagnoses
                                                                             Explanation        of (Circle appropriate diagnoses)
                                                                             Abnormal
                                                                             Assessment Factors
Abdomen:         Soft Firm Hard Tender Distended _____cm.                                      Breastfeeding, Effective
                 Scaphoid No Masses                                                               Breastfeeding, Ineffective
                                                                                                    Breastfeeding, Interrupted
Bowel Sounds: Active Hyper Hypo Absent                                                          Fluid Volume, Deficit
Flatus: Yes No                                                                                    Fluid Volume, Deficit, Risk for
                                                                                                    Infant Feeding Pattern,
Diet:Breastfeeding       Bottlefeeding     Both
                                                                                                      Ineffective
Formula: Type _______________                                                                       Nutrition: Imbalanced, Risk for
Feeding Vigor: _______________                                                                        More Than Body
                                                                                                      Requirements
Mucous Membranes: Moist Dry Thrush Epstein’s pearls                                             Nutrition: Imbalanced, More
Pink Dusky Precocious teeth Sucking pads                                                          Than Body Requirements
Mouth:           Lips/palate intact    Tongue – normal size/movement                              Nutrition: Readiness for
                                                                                                      Enhanced
Reflexes: Rooting       Sucking       Swallowing       Gag                                      Oral Mucous Membranes,
                                                                                                      Impaired
Diet Toleration: Well Regurgitates Projectile vomiting
                                                                                                    Swallowing, Impaired
24o Intake _______________ # wet/soiled diapers/24 o _______________
Blood Glucose Monitoring q ___ hrs Time/Result _____________ N/A

C. ELIMINATION                                                                                      Constipation
                                                                                                    Constipation, Risk for
         1.     BOWEL                                                                               Diarrhea
Stool:   Meconium Transitional Mature Frequency/24 o
         Color:                    Consistency
Anus:        Patent   Pilonidal dimple     Imperforate anus

         2.     URINARY                                                                             Fluid Volume, Risk for
                                                                                                       Imbalanced
Urine:       Clear Cloudy Sediment                                                               Infection, Risk for
Odor:        Faint Offensive                                                                      Tissue Perfusion, Ineffective
Color:       Light Yellow Dark Yellow Orange Clots Hematuria                                   Urinary Elimination, Impaired
Time of first voiding _______________ Frequency/24 o                                                Urinary Retention
Genitalia:      No Anomalies           Male: Hypospadius Epispadius
                Circumcision Type _______________ Care

D. ACTIVITY/REST                                                                                    Activity Intolerance
                                                                                                    Activity Intolerance, Risk for
Periods of Reactivity: N/A       First    Sleep      Second                                     Fatigue
States noted: Deep sleep      Light sleep Drowsy Quiet alert                                    Infant Behavior, Disorganized
Active Alert Crying          Habituation to stimuli Self-consoling                              Mobility, Impaired Physical
Activities: Hands to mouth       Sucking         Watching objects                                Parent/Infant Attachment,
                                                                                                       Impaired
Orientation to stimuli: Visual        Auditory                                                    Parenting, Impaired, Risk for
Parent’s response to infant                                                                         Sleep Deprivation
                                                                                                    Sleep Pattern, Disturbed




                                                                       -8-
E. COMFORT                                                                                 Date/Time            Related Nursing Diagnoses
                                                                                           Explanation of       (Circle appropriate diagnoses)
                                                                                           Abnormal
                                                                                           Assessment Factors
Pain/Discomfort Signs/Symptoms: Changes in VS                Changes in O2 sat. levels                        Comfort
                                                                                                                Pain, Acute
Irritable     crying     Changes in eating/sleeping                                                         Pain, Chronic
Pain Relief Meaures: Anesthetic/Analgesic          Type                                                        Safety and Security
                                                                                                                Temperature
Pacifier     Music      Rocking        Talking softly                                                       Hyperthermia
                                                                                                                Hypothermia
F. SEXUAL
                                                                                                                Temperature, Risk for
Breasts: Symmetrical Asymmetrical Supernumerary nipples                                                         Imbalanced Body
Discharge ___________________________ Amt. breast tissue                              cm                        Thermoregulation, Ineffective
                                                                                                                Skin
Female genitalia: Majora > minora          Swollen        Discharge                                          Infection, Risk for
Pseudomenstruation        Hymenal tags                                                                        Injury, Risk for
                                                                                                                Latex Allergy Response
Male genitalia: Rugae present         Hydrocele       Prepuce nonretractable                                 Latex Allergy Response,
Testes  bilat.                                                                                                   Risk for
                                                                                                                Protection, Ineffective
Ambiguous genitalia: No           Yes     Describe                                                            Skin Integrity, Impaired
                                                                                                                Skin Integrity, Impaired,
II. SAFETY AND SECURITY                                                                                            Risk for
                                                                                                                Tissue Integrity, Impaired
Temperature: ________ Route Taken: Ax.                Rectal    Skin                                         Physical
Skin:       Turgor: Location: ________ Elastic Tented Taut Shiny                                            Growth, Risk for
                                                                                                                   Disproportional
            Temp:     Hot Warm Cool Dry Clammy Diaphoretic                                                Injury, Risk for
Vernix      Lanugo       Erythema toxicum        Milia       Petechaie                                     Mobility, Impaired Physical
Ecchymosis         Forcep marks                                                                               Trauma, Risk for
                                                                                                                Surgical Recovery, Delayed
Location
                                                                                                                Perception
Other                                                                                                           Energy Field Disturbed
                                                                                                                Environmental Interpretation
Pigment:      Mongolian spots Telangiectatic nevus                                                               Syndrome, Impaired
              Nevus flammeus        Nevus vasculosus                                                          Infant Behavior, Disorganized
Location                                                                                                        Infant Behavior, Disorganized,
                                                                                                                   Risk for
Umbilical cord:       3 vessels     Dry/intact       Clamped                                                 Infant Behavior, Readiness for
                      Cord care type __________          Diaper  cord                                           Enhanced Organized
                                                                                                                Poisoning, Risk for
Physical:                                                                                                       Sensory/Perception,
Clavicle:       Intact    Crepitus/location                                                                      Disturbed (specify):
                                                                                                                   Visual, Kinesthetic, Auditory,
Legs/arms:     10 toes/fingers      Symmetrical        Syndactyly                                               Gustatory, Tactile, Olfactory
               Polydactly     Simian creases                                                                  Unilateral Neglect

Hips:          Gluteal folds equal       Neg. hip click
Spine:         Straight     Intact      Spinal cysts/hair/sinuses
Prophylaxis: Erthromycin o.u. given          Vitamin K given
               HBIG given         Hepatitis B vaccine given
Newborn Screening Tests – List
Other:        ID band on arm/leg       Mother’s band matches
              Infant on back when in crib      Bulb syringe in crib
              Nothing by infant’s face




                                                                         -9-
Section 2: Psychosocial Assessment
Note: It is not appropriate to ask the client direct questions as you would during a history. Information is obtained by
         observing verbal and nonverbal behaviors and making inferences as you and the patient work toward accomplishing
         goals and objectives.
III.    LOVE AND BELONGING                                                                     Related Nursing Diagnoses
1. Emotional State                                                                             Adjustment, Impaired
     a. What seems to be the client’s mood? -Normal for Age/Culture                            Caregiver Role Strain
        Withdrawn Depressed Anxious Fearful Uncooperative                                 Caregiver Role Strain, Risk for
        Flat Affect Elevated Euphoric Expressive Other                                    Communication, Impaired
                                                                                                  Verbal
2. Client’s Life Experience
                                                                                               Communication, Readiness for Enhanced
     a.   How have previous life experiences affected the client’s perception of the current   Community Coping, Ineffective
          health problems?                                                                     Community Coping, Readiness
                                                                                                  for Enhanced
                                                                                               Delayed Development, Risk for
                                                                                               Family Coping: Compromised,
                                                                                                  Ineffective
     b.   How has life changed as a result of the current health problem?                      Family Coping: Disabled
                                                                                               Family Coping: Readiness for Enhanced
                                                                                               Family Processes, Dysfunctional:
                                                                                                  Alcoholism
                                                                                               Family Processes, Interrupted
     c.   Describe any signs or symptoms that may indicate actual/potential                    Family Processes, Readiness for
          physical/emotional abuse.                                                               Enhanced
                                                                                               Growth and Development, Delayed
                                                                                               Loneliness, Risk for
                                                                                               Parental Role Conflict
                                                                                               Parent/Infant/Child Attachment,
3.   Family                                                                                       Impaired, Risk for
     a.   What is the client and family’s perception of the illness/admission?                 Parenting, Impaired
                                                                                               Parenting, Impaired, Risk for
                                                                                               Parenting, Readiness for Enhanced
                                                                                               Role Performance, Ineffective
                                                                                               Social Interaction, Impaired
     b.   What evidence indicates that family life has changed?                                Social Isolation
                                                                                               Violence, Risk for

     c.   How do family members seem to be coping?


     d.   What supportive behaviors from family/significant others are evident?


4.   Erikson/Newman/Newman Developmental Stage:

     a.   What task is appropriate for this stage of development?



     b.   How has this health problem interfered with accomplishing the development tasks
          for this client?




W:NEWBORNCAREPLAN:1/06                                        -16-
     c.   What evidence indicates negative or positive developmental resolution?




IV.     SELF-ESTEEM:                                                                         Related Nursing Diagnoses
1. Self-Esteem and Body Image                                                                Self-Esteem
     a.   How is the client’s self-esteem threatened by this illness/admission?              Adjustment, Impaired
                                                                                             Anxiety
                                                                                             Body Image Disturbed
                                                                                             Coping, Defensive
     b.   What is the client’s perception of body image and how has it changed?
                                                                                             Coping, Ineffective
                                                                                             Death Anxiety
                                                                                             Decisional Conflict (Specify)
     c.   What fears/concerns were expressed by the client that relate to client’s present   Denial, Ineffective
          illness?                                                                           Fear
                                                                                             Grieving, Anticipatory
                                                                                             Grieving, Dysfunctional
2.   Culture                                                                                 Grieving, Dysfunctional, Risk for
                                                                                             Hopelessness
     a.   What is the client’s ethnic background?
                                                                                             Personal Identity, Disturbed
                                                                                             Post-Trauma Syndrome
     b.   How does culture/language influence communication between client/family and
                                                                                             Post-Trauma Syndrome, Risk for
          healthcare workers?                                                                Powerlessness
                                                                                             Powerlessness, Risk for
                                                                                             Rape-Trauma Syndrome
     c.   Which communication factors are relevant and why do you think so?                  Rape-Trauma Syndrome, Compound
                                                                                                Reaction
          (Touch, personal space, eye contact, facial expressions, body language)
                                                                                             Rape-Trauma Syndrome, Silent
                                                                                                Reaction
                                                                                             Relocation Stress Syndrome
     d.   Who seems to be making the healthcare decisions in the family?                     Relocation Stress Syndrome, Risk for
                                                                                             Self-Esteem, Chronic Low
                                                                                             Self-Esteem, Situational Low
     e.   Based on your observations, what role does each family member play?                Self-Esteem, Situational Low, Risk for
                                                                                             Sorrow, Chronic
                                                                                             Spiritual Distress
     f.   Who is responsible for care of a sick family member at home?                       Spiritual Distress, Risk for
                                                                                             Spiritual Well-Being,
                                                                                                Readiness for Enhanced
     g.   What cultural practices related to hospitalization need to be considered?          Self-Actualization
                                                                                             Health Maintenance, Ineffective
                                                                                             Health Seeking Behaviors (Specify)
3.   Spirituality                                                                            Home Maintenance, Impaired
                                                                                             Knowledge, Deficient (Specify)
     a.   What spiritual/religious beliefs does the client express?                          Knowledge, Readiness for Enhanced
                                                                                                (Specify)
                                                                                             Noncompliance
     b.   What signs and symptoms if present indicate spiritual distress?                    Therapeutic Regimen: Community,
                                                                                                Ineffective Management of
                                                                                             Therapeutic Regimen: Families,
     c.   What spiritual practices related to hospitalization need to be considered?            Ineffective Management of
                                                                                             Therapeutic Regimen: Management,
                                                                                                Effective
                                                                                             Therapeutic Regimen: Management,



W:NEWBORNCAREPLAN:1/06                                             -17-
V.        SELF-ACTUALIZATION                                                                  Ineffective
                                                                                            Therapeutic Regimen: Management,
1.   What is the client’s/family’s current level of understanding of their health/illness     Readiness for Enhanced
     problem?



2.   What type of relationship exists with healthcare providers?




W:NEWBORNCAREPLAN:1/06                                         -18-

				
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