Newborn Hypothermia and Hyperthermia(Final Copy)

MINDANAO SANITARIUM AND HOSPITAL COLLEGEBrgy. San Miguel, Iligan City 9200

SCHOOL OF NURSINGAy. 2009-2010

NEWBORN HYPOTHERMIA ANDHYPERTHERMIA

SUBMITTED BY:Syra Allison C. Dimco, BSN-2NC

Marycris A. Pagapula-an, BSN-2NB

SUBMITTED TO:Karla B. Orbeta, RN

Systems AssessmentIntegumentary Normal:

When the is delivered, the newborn will appear cyanotic only for 24 hours. Color in Cuacasian infants usually pink; varies with other ethnic

backgrounds. Pigmentation increases after birth. Skin may be dry. Small amounts of lanugo and vernix caseosa still seen.

Hypothermia:Inspection

Acrocyanosis The newborn is chilling

Palpation Cold extremities

Hyperthermia:Inspection

The skin is pale Flushed skin Profuse sweating

Palpation Warm extremities

Respiratory Normal: The newborn’s normal respiratory rate is 30-60 breaths per minute with

short periods of apnea (<15 seconds). Chest and abdomen rise simultaneously; no seesaw breathing.

Inspection Rapid respiration Apnea

Auscultation Tachycardia Increased respiratory rate, greater that 60 bpm

Circulatory Normal: Heart rate averages 140 beats per minute at birth, with chages noted

during sleep. Ductus arteriosus constricts with establishment of respiratory function;

later becomes ligament (2-3 months).Inpection

Inpect for signs of hypoxia Cyanosis Rapid respiration

Palpation Cold extremities

Auscultation Respiratory rate greater that 60 bpm Tachycardia

Neurologic Reflexes present at birth: Rooting, sucking, and swallowing. Tonic neck, “fencing” attitude. Grasp: newborn’s fingers curl around anything placed in palm. Moro reflex: symmetric and bilateral abduction and extension of arms and

hands; thumb and forefinger form a C; the “embrace” reflex. Startle reflex: similar to Moro, but with hands clenched. Babinski’s sign: flare of toes when foot stroked from base of heel along

lateral edge to great toe.Inpection

Assess for any absence of the following reflexes for further evaluation of the newborn’s condition.

Anatomy and Physiology

Temperature Regulation

Temperature regulation is the maintenanace of thermal balance of the loss of heat to the environment at a rare equal to the production of heat. Newborns are homeothermic; they attempt to stabilize their internal (core) body temperatures within a narrow range in spite of significant temperature variations in their enviromnment.

Thermoregulation in the newborn is closely related to the rate of metabolism and oxygen consumption. Within a specifis environmental range called the thermal neutral zone (TNZ), the rates of oxygen consumption and metabolism are minimal, and internal body temperature is maintained because of thermal balance. For an unclothed full-term newborn, the TNZ range is ambient temperature of 32 to 34C (89.6-93.2F). the limits for an adult are 26 to 28C (78.8-82.4F). thus, the4 normal newborn requires higher environmental temperature to maintain a thermoneutral environment than does the adult.

Table 1.1Laboratory Data Normal RangeHemoglobin 15-20 g/dLHematocrit 43%-61%WBC 10,000-30,000/mm3

Neutrophils 40%-80%Immature WBC 3%-10%Platelets 100,000-280,000/mm3

Reticulocytes 3%-6%Blood volume 82.3mL/kg (third day after early cord clamping)

92.6 mL/kg (third day after delayed cord clamping)

Sodium mmol/L 124-156Potasssium mmol/L 5.3-7.3Chloride mmol/L 90-111Calcium mg/dL 7.3-9.2Glucose mg/dL 40-97

Types of Heat Loss

A newborn is at a distinct disadvantage in maintaining a normal temperature because of its larger body suface in relation to mass and limited amount of insulating subcutaneous fat. With a body weight approximately 5 percent of the adult’s and body surface nearly 15 percent of the adult’s, the full-term newborn loses about four times as much ehat as an adult.

Convection

Is the loss of heat from the warm body surface to the cooler air currents. Air-conditioned rooms, oxygen by mask, and removal from an overhead warmer increase connective heat loss of the neonate.

Radiation

Losses occur when heat transfers from the heated body surface to cooler surfaces and objects not in direct contact with the body. The walls of a room or of an incubator are potential causes of heat loss by radiation, even if the ambient temperature of the isolette is within the thermal neutral range for that infant.

Evaporation

Is the loss of heat incurred when water is converted to a vapor. The newborn is particularly prone to lose heat by evaporation immediately after delivery, when the infant is wet with amniotic fluid, and during baths.

Conduction

Is the loss of heat to a cooler surface by direct skin contact. Chilled hands, cool scales, cold examination tables, and cold stethoscopes can cause loss of heat by conduction.

Table 1.2Age and Weight Range of Temperature

(oC)Age and Weight Range of

Temperature (oC)0-6 hours 72-96 hoursUnder 1200 g 34.0-35.4 Under 1200 g 34.0-35.01200-1500 g 33.9-34.4 1200-1500 g 33.0-34.01501-2500 g 32.8-33.8 1501-2500 g 31.1-33.2Over 2500 (and > 36 weeks)

32.0-33.8 Over 2500 (and > 36 weeks)

29.8-32.8

6-12 hours 4-12 daysUnder 1200 g 34.0-35.4 Under 1500 g 33.0-34.01200-1500 g 33.5-34.4 1501-2500 g 31.0-33.21501-2500 g 32.2-33.8 Over 2500 ( and >

36 weeks)Over 2500 (and > 36 weeks)

31.4-33.8 4-5 days 29.5-32.6

12-24 hours 5-6 days 29.4-32.3Under 1200 g 34.0-35.4 6-8 days 29.0-32.21200-1500 g 33.3-34.3 8-10 days 29.0-31.81501-2500 g 31.8-33.8 10-12 days 29.0-31.4Over 2500 (and > 36 weeks)

31.0-33.7 12-14 days

24-36 hours Under 1500 g 32.6-34.0Under 1200 g 34.0-35.0 1500-2500 g 31.0-32.21200-1500 g 33.1-34.2 Over 2500 ( and >

36 weeks)29.0-30.8

1501-2500 g 31.6-33.6 2-3 weeksOver 2500 (and > 36 weeks)

30.7-33.5 Under 1500 g 32.2-34.0

36-48 hours 1500-2500 g 30.5-33.0Under 1200 g 34.0-35.0 3-4 weeks1200-1500 g 33.0-34.1 Under 1500 g 31.6-33.61501-2500 g 31.4-33.5 1500-2500 g 30.0-32.7Over 2500 (and > 36 weeks)

30.5-33.3 4-5 weeks

48-72 hours Under 1500 g 31.2-33.0Under 1200 g 34.0-35.0 1500-2500 g 29.5-32.21200-1500 g 33.0-34.0 5-6 weeks1501-2500 g 31.2-33.4 Under 1500 g 30.6-32.3Over 2500 (and > 36 weeks)

30.1-33.2 1500-2500 g 29.0-31.8

For this table,scopes had the walls of incubator 1-2o warmer than the ambient air temperatures. Generally speaking, the smaller infants in each weight group will require a temperature in a higher portion of the temperature range. Within each time range,the younger the infant, the higher temperature required.

Heat Production

Upon being exposed to a cool environment, the neonate requires additional heat. Several sources of heat production, or thermogenesis, are available, icluding increased basal metabolic rate, muscular activity, and chemical thermogenesis (also referred as nonshivering thermogenesis) mediated through the release of catecholamines.

Nonshivering Thermogenesis

Nonshivering thermogenesis is unique to the newborn’s stores of brown adipose tissue. Brown adipose tissue (BAT), or brown fat, is the primary source of heat in the cold-stressed newborn. It first appears in the fetus at 26-30 weeks of gestation and continues to increase in supply until 2-5 weeks after the birth of a full-term neonate, unless it is depleted by cold stress. Brown fat is deposited in the midscapular area, around the neck, and in the axillas, with deeper placement around the trachea, esophagus, abdominal aorta, kidneys, and adrenal glands. It continues 2 percent to 6 percent of the newborn’s total body weight. Brown fat receives its name from its dark color, which is due to enriched blood supply, dense cellular content, and abundant nerve endings.

Brown Fat

The structures of brown and white fat cells differ, as do their function. In brown fat, the large numbers of fat cells facilitates the speed with which triglycerides can be metabolized to produce heat. Energy is provided by the presence of glycogen and large numbers of mitochondria releasing adenosine triphosphate (ATP) for rapid metabolic turnover and production of heat. In addition, brown fat possesses a rich blood supply to enhance the distribution of heat throughout the body, and a nerve supply for initiation of metabolic activity. This type of metabolism is specific to the newborn. The brown fat is metabolized and used within several weeks after birth.

Chemical Thermogenesis

Chemical thermogenesis occurs when skin receptors perceive environmental temperature changes and transmit sensations to the CNS, which in turn stimulates the sympathetic nervous system. Release of norepinephrine by the adrenal gland and at a local nerve endings in the brown fat causes the metabolism of the triglycerides to fatty acids, thereby releasing heat to be distributed to the body. Brown fat is a major producer of heat for the cold-stressed neonate because of its greater heat production capacity.

Response to Heat

Sweating is the usual initial response of the newborn to hyperthermia. The neonate has six times as many sweat glands as the adults, but the newborn’s activity level is one-third than of the adult. The glands have limited function until after the fourth week of extrauterine life. Dissipation of heat is accomplished by peripheral vasodilation and evaporation of insensible water loss. Oxygen consumption and metabolic rate also increases in response to hyperthermia.

Pathophysiology

Hypothermia

Shivering, a form of muscular activity common in the adult, is rarely seen in the newborn, although it has been observed at ambient temperatures of 15C (59F) or less. If shivering does appear, it means the infant’s metabolism rate has alreadt doubled and the extra muscular activity does little to produce needed heat.

After being exposed to cold, thermographic studies of newborns show an increase in the skin heat over the brown fat deposits in the neonate between 1 and 14 days of age. If the drown fat supply has been depleted, the metabolis response to cold will be limited or lacking. An increase in metabolism as a result of hypothermia results in increase oxygen consumption.

After birth,the highest losses of heat generally result from radiation and convection because of the newborn’s large body surface compared with weight, and from thermal conduction because of the marked difference between core temperature and skin temperature.

Hypethermia

Since the newborn’s systems are still immature, peripheral vasodilation is not an effective mechanism as well as dissipation of heat is unlikely not successful that’s why newborn’s metabolic rate have to increase which causes more complications.

See the flow charts....

Flow Chart:

Newborn Hypothermia and Hyperthermia

Precipitating Factors Predisposing Factors -Exposure to environmental factors -Inadequate prenatal care

Cold -Preterm infants Too Hot -Sick babies

-Exposure to pathogens -Low birth weight and less

BAT stores

↓Immature thermoregulation

↓ Exposure to environmental factors

↓ body’s response to the presence

Radiation, Conduction, Convection, Overheating of pathogens

and Evaporation ↓ ↓ ↓ ↑ body temperature (systemic inflammatory response)Heat Transfer ↓ ↓

The newborn experiences heat loss Peripheral Vasodilation ↑ perspiration ↑ Metabolic rate(↓ temperature) ↓ ↓ ↓ ↓ Dissipation of heat ↑ loss of body fluids ↑ O2 consumption

Peripheral Vasoconstriction ↓ through sweating and ↑ glucose use ↓ Further ↑ in body temp. ↓

Dehydration NST ↑ Metabolic rate ↓Metabolism of Brown Fat ↑ O2 ↑ glucose use ↓ consumption ↓Depletion of ↓ depletion of brown fat ↓ surfactant glycogen stores

production

Further ↓ in body temperature

Signs and Symptoms

Respiratory Endocrine Circulatory Integumentary-dyspnea -hypoglycemia -hypoxia -↓ body temperature-apnea -hypoxemia -↑ body temperature-tachycardia -metabolic acidosis -pallor

-cold extremities-acrocyanosis-profuse sweating-warm flushed skin

Legend:

Hypothermia-Hyperthermia By: Syra Allison Dimco

Nursing Care Plan (NCP)

Nursing Diagnosis: Ineffective thermoregulation: Hypothermia r/t immature compensation for changes in the environmental temperature.

Cues Objective Nursing Intervention Rationale Evaluation

Subjective cues:

Objective cues:

-Temp.- Higher than normal range which is 36.5-37 oC-RR- Higher than normal range which is 30-60 BPM-HR- Higher than normal range which is 120-160 BPM-Cyanosis-Cold extremities-Chilling

STO:

Within 10-30 minutes of providing immediate nursing care to the newborn such as, immediately drying the newborn, covering it with warm linen and putting it into preheated radiant warmer or incubator as necessary, newborn will be prevented of losing too much heat, as evidence by absence of chilling and cyanosis.

LTO:

Within 2-3 days of rendering nursing care to the newborn such as, maintaining warm environment within newborn’s capacity to adopt through skin-to-skin contact with the mother every 1-2 hours a day, putting it in the incubator as necessary with proper monitoring, newborn will be able to maintain and regulate body temperature within expected normal range.

Independent:

Note contributing factors, (e.g. premature neonate, CNS trauma, near-down problems, sepsis, hypothyroidism.)

Assess environment for possible sources of heat loss through evaporation, conduction, convection, or radiation.

Check radiant heat source or isolette.

Prewarm all blankets and equipment that come in contact with the newborn.

Immediately dry the newborn thoroughly with clean soft preferably warm towel. Use another warm towel to wrap the baby in two layers.

Ensure that the head is well covered and avoid the newborn contact with cold surfaces.

Put the newborn under preheated radiant warmer or in the incubator as necessary.

To know any underlying problems.

To minimize risk of heat loss.

To ensure maintenance of appropriate temperature of the environment

To minimize heat loss.

To prevent rapid heat loss through evaporation.

To minimize heat loss.

Assists in maintaining the temperature of infant. To help the newborn regulate and maintain normal body temperature.

After providing care to the newborn such as maintaining good warm environment within newborn’s capacity to adopt and proper monitoring of temperature with proper parents instruction, both short and long term objectives were achieved as evidence by newborn is able to maintain and regulate body temperature within expected normal range.

Monitor temperature frequently (at least 3 hours), blood pressure, heart and breathing rates, and oxygen levels.

Assess respiratory status effort.

Auscultate lungs, noting adventitious sounds.

Monitor heart rate and rhythm.

Monitor blood pressure, noting hypotension.

Measure urine output.

Monitor laboratory studies, such as ABCs, CBC, and electrolytes.

Maintain patent airway, assist in intubation if indicated, and provide heated humidified oxygen when used.

Turn off warming blankets when temperature is within1-3 degrees to prevent hyperthermia.

To know possible significant changes or to identify deviations that could suddenly occur.

Rate and tidal volume are reduced when metabolic rate decreases and respiratory acidosis occurs.

Pulmonary edema, respiratory infection, and pulmonary embolus are possible complications of hypothermia.

Cold stress reduces peacemaker function, and bradycardia (unresponsive to atropine), atrial fibrillation, atrioventricular blocks, and ventricular tachycardia can occur.

Hypotension can occur due to vasoconstriction and shunting of fluids as a result of cold injury effect on capillary permeability.

Oliguria can occur due to low flow state and/or following hypothermic osmotic diuresis.

Respiratory and metabolic acidosis, increased hematocrit, decreased white blood cell count may manifest.

To prevent further heat loss.

To avoid hyperthermia situation since the infant is still cannot regulate its own temperature.

Encourage kangaroo care (mother holds the infant underneath her clothing skin-to-skin and upright between her breast)

Avoid bathing the infant if temperature is not yet stable.

Educate parents on how to maintain a neutral thermal environment, including importance of keeping the newborn warm with a cap and double-wrapping with blankets and changing them frequently to keep dry.

(If the infant can be already bath)In bathing the baby:

- Ensure before giving bath that temperature is normal.

- Use warm room and warm water.

- Bathe quickly and gently.- Dry quickly and thoroughly

from heat to toe.- Wrap in a warm dry towel.- Dress and wrap infant, use a

cap on the head.- Place infant close to the

mother.

Collaborative:

Refer to social services or a dietitian as appropriate.

To provide warmth and contact which aid in parent-infant attachment. Assists in maintaining the temperature of infant.

To prevent cold stress.

To promote newborn’s adjustment.

Preventive approaches decrease the risk of heat loss or hypothermia.


Nursing Diagnosis: Ineffective thermoregulation: Hyperthermia r/t immature compensation for changes in the environmental temperature and/or presence of endogenous pathogens.


Subjective cues:

Objective cues:

-Temp.- Higher than normal range which is 36.5-37 oC-RR- Higher than normal range which is 30-60 BPM-HR- Higher than normal range which is 120-160 BPM-Warm and clammy skin-Sweating-Pallor-Tachycardia

STO:

Within 10-30 minutes of providing immediate nursing care to the newborn such as, providing good temperature by not over wrapping the baby and avoiding it expose with too much heat, newborn will be prevented of gaining too much heat as evidence by absence of profuse sweating and irritability.

LTO:

Within 2-3 days of proving nursing care to the newborn such as maintaining good temperature (not too hot) with proper aseptic technique in giving care, newborn will be prevented of developing infection as evidence by absence of fever.

Independent:

Assess neurological response, noting level of consciousness and orientation and reaction to stimuli, reaction of pupils, and presence of posturing or seizures.

Assess environment for possible sources of heat gain through evaporation, conduction, convection, or radiation.

Monitor temperature frequently (at least 3 hours), blood pressure, heart and breathing rates, and oxygen levels.

Monitor heart rate and rhythm.

Monitor respirations. Auscultate breath sounds, noting adventitious sounds such as crackles.

Monitor, record, and assess all sources of fluid loss such as urine, and insensible losses.

Note presence/absence of sweating as the newborn’s body attempts to increase heat loss by evaporation,

For proper assessment to the severity of problem.

To minimize risk of heat gain.

To know possible significant changes or to identify deviations that could suddenly occur.

Dysrhythmias and ECG changes are common due to electrolyte imbalance.

Hyperventilation may initially be present but ventilatory effort may eventually be impaired due to immature system.

That could indicate oliguria, potentiates fluid and electrolyte losses.

Evaporation is decreased by environmental factors of high humidity and high ambient temperature, as

After maintaining core temperature within newborn’s capacity to adopt and proper observation of aseptic technique in giving care both short and long term objectives were achieved as evidence by newborn is able to maintain and regulate body temperature within expected normal range and is prevented of developing infection.

conduction, and diffusion.

Provide tepid sponge bath but avoid using alcohol as solution.

Promote surface cooling by undressing or not double-wrapping the infant.

Observe aseptic technique in giving care to the newborn with proper handling.

Provide tube feedings, or parenteral nutrition.

Provide supplemental oxygen.

Avoid infant contact with hot surfaces.

Instruct parents to avoid leaving the newborn unattended.

Monitor fluid intake, through IV.

Educate parents about that importance not double wrapping the newborn.

Monitor laboratory studies such as ABCs, electrolytes, cardiac and liver enzymes, glucose urinalysis, and coagulation profile.

Collaborative:

well as body factors producing inability to sweat or sweat gland dysfunction (e.g. spinal cord transection.)

May help reduce fever. Ice water or alcohol may cause chills actually elevating temperature.

To promote heat loss in the body.

To prevent development or further development of infection.

To meet metabolic demands.

To offset increased oxygen demand and consumption.

To prevent further heat gain.

To prevent heat injury/death.

To prevent dehydration.

To prevent too much heat gain.

May reveal tissue degeneration, myoglobinuria, proteinuria, and hemoglobinuria.

Refer to social services or a dietitian as appropriate.

Preventive approaches decrease the risk of heat loss or hypothermia.


Nursing Diagnosis: Ineffective breathing pattern r/t increase respiratory drive secondary to increased O2 consumption.


Subjective cues:

Objective cues:

-Temp.- Higher than normal range which is 36.5-37 oC-RR- Higher than normal range which is 30-60 BPM-HR- Higher than normal range which is 120-160 BPM-Dyspnea-Slightly cyanotic

STO:

Within 10-30 minutes of providing immediate nursing care to the newborn such as, administering 1-2 L of O2 via nasal cannula with proper monitoring of RR and breathing pattern, newborn will be able to attain normal breathing pattern as evidence by absence of apnea and dyspnea.

LTO:

Within 2-3 days of proving nursing care to the newborn such as proper maintenance of oxygen and maintaining neutral thermal environment to reduce oxygen consumption, newborn will be able to maintain normal breathing Pattern and maintain respiratory rate within expected normal range.

Suction secretions properly, mouth and nasopharynx with bulb syringe or using the suction machine with suction catheter as needed.

With mechanical suction, limit each suctioning attempt to 10-15 seconds, with sufficient time in between attempt.

Assess gestational age and risk factors for respiratory distress.

Anticipate need for bag and mask setup and wall suction.

Assess the respiratory effort.

Observe for cues (grunting, shallow respirations, tachypnea, apnea, tachycardia, central cyanosis, hypotonic, increased effort).

Assess skin color.

Maintain slight head elevation.

Monitor oxygen saturation level via pulse oximetry.

To provide patent airway and aspiration of fluid.

To allow oxygenation.

To allow early detection.

To allow for prompt intervention should respiratory status continue to worsen.

To identify changes.

To identify newborn’s need for additional oxygen.

To evaluate tissue perfusion.

To prevent upper airway obstruction.

To provide objective indication of perfusion status.

After 10-30 mins. of providing supplemental oxygen with proper monitoring of RR as well as the breathing pattern, newborn is able to attain normal breathing pattern, and within 2-3 days of rendering nursing care, newborn is able to maintain normal breathing pattern and normal respiratory rate, within expected normal range.

Provide supplemental oxygen as indicated and ordered.

Assist with any ordered diagnostic test, such as chest x-ray and arterial blood gases.

Maintain a neutral thermal environment.

Monitor hydration status.

Position infant right side after feeding.

Explain all events and procedures to the parents.

Inform parents that the rapid respiratory rate is common in some newborns after birth because increase oxygen demand.

Monitor newborn’s temperature and keep him/her warm via radiant warmer. Wrap the newborn loosely in a blanket and place a cap on his/her head.

To ensure adequate tissue oxygenation.

To determine effectiveness of treatments.

To reduce oxygen consumption.

To prevent fluid volume deficit or overload.

To prevent aspiration.

To help alleviate anxiety and promote understanding of newborn’s condition.

Providing information helps to allay parent’s anxieties and fears.

Newborns have difficulty conserving body heat. Exposure to cold increases the metabolic rate, increasing the need for oxygen and further increasing the respiratory rate.


Nursing Diagnosis: Fluid volume deficit r/t insensible fluid loss and profuse sweating.


Subjective cues:

Objective cues:

-Temp.- Higher than normal range which is 36.5-37 oC-RR- Higher than normal range which is 30-60 BPM-HR- Higher than normal range which is 120-160 BPM-Tachycardia-dry skin-Profuse sweating-Pallor-Dry lips-Slow capillary refill

STO:

Within 10-30 minutes of providing supplemental fluids to the newborn as well as providing a thermo neutral environment, newborn will be prevented of too much fluid loss as evidence by the absence of sweating and adequate urinary output.

LTO:

Within 2-3 days of proving nursing care to the newborn such as continuation of providing supplemental fluids and proper monitoring of intake and output, newborn will be able to maintain fluid and electrolytes balance as evidence by absence of dehydration.

Independent:

Note infant’s level of dehydration, and mentation.

Provide supplemental fluids.

Monitor and record vital signs (temp, RR, HR) closely for at least every 3-4 hours interval.

Auscultate blood pressure, calculate pulse pressure.

Maintain a thermo neutral environment but not too cold.

Monitor and record intake and output accurately. Note number, character, and amount of stools.

Estimate/ calculate insensible fluid losses.

Estimate insensible fluid losses; e.g. diaphoresis. Measure urine specific gravity; observe for oliguria.

Provides information regarding ability to tolerate fluctuations in fluid level and risk for creating or failing to respond to problem.

For immediate replacement of fluid loss.

Tachycardia, fever can indicate response to and/or effect of fluid loss.

Pulse pressure widens before systolic BP drops in response to fluid loss.

To minimize O2 consumption as well as minimize sweating.

Provides information about overall fluid balance, and bowel control, as well as guidelines for fluid replacement.

To include in replacement calculations.

To have accurate information about fluid loss for proper replacement.

Within 10-30 minutes of providing supplemental fluids to the newborn as well as providing a thermo neutral environment, newborn is prevented of too much fluid loss as evidence by the absence of sweating and adequate urinary output, and within 2-3 days of proving nursing care to the newborn such as continuation of providing supplemental fluids and proper monitoring of intake and output, newborn is able to maintain fluid and electrolytes balance as evidence by absence of dehydration.

Observe for excessively dry skin and mucous membranes, decreased skin turgor, slowed capillary refill.

Note generalized muscle weakness or cardiac dysrhythmias.

Weigh daily, as indicated, and evaluate changes as they relate to fluid status.

Educate parents about the infant’s situation or condition.

Collaborative:

Administer parenteral fluids as indicated.

Monitor laboratory results e.g. electrolytes, acid-base balance.

Indicates excessive fluid loss/ resultant dehydration.

To know other possible health problems such as intestinal loss.

To know any improvements or the severity of problem,

Proper information to the concerned parents will reduce anxiety.

Loss of fluids really requires fluid replacement to correct losses.

Determines replacement needs and effectiveness of the therapy.


Nursing Diagnosis: Ineffective tissue perfusion r/t imbalanced O2 supply and demand


Subjective cues:

Objective cues:

STO:

Within 10-30 minutes of providing immediate nursing care to the newborn such as, administering 1-2 L of O2 via nasal cannula with proper monitoring of RR and breathing pattern, as well as providing neutral thermal environment, newborn will show improvements in condition as evidence by normal breathing pattern.

LTO:

Within 1-2 days of rendering nursing care such as maintenance of oxygen as necessary and proper core temperature, newborn will be able to maintain the expected outcome as evidence by normal breathing pattern and absence of weakness.

Independent:

Immediately provide supplemental oxygen 1-2 L or as necessary.

Determine factors related to the infant’s situation or condition.

Note presence of conditions/situations that can affect multiple systems (e.g. brain injury, sepsis, systemic lupus, etc.).

Evaluate for signs of infection.

Maintain patent airway.

Note customary baseline data (e.g. usual BP, weight, mentation, ABGs, and other appropriate laboratory study.)

Determine presence of visual, sensory/motor changes.

Measure circumference of extremities, as indicated

Assess lower skin extremities, noting

To promote proper breathing.

To have an appropriate idea of the proper intervention that should be given.

To know any possible underlying complications.

The infant’s immune system is still not well developed, thus it is prone to infection.

To promote oxygenation.

Provides comparison with current findings.

Suggestive of a transient ischemic attack.

Useful in identifying edema in involved extremity.

For more information.

Within 10-30 minutes of providing immediate nursing care to the newborn such as, administering 1-2 L of O2 via nasal cannula with proper monitoring of RR and breathing pattern, as well as providing neutral thermal environment, newborn was able to show improvements in condition as evidence by normal breathing pattern, and within 1-2 days of rendering nursing care such as maintenance of oxygen as necessary and proper core temperature, newborn is able to maintain the expected outcome as evidence by normal breathing pattern and absence of weakness.

skin texture; absence of body hair: presence of edema.

Measure capillary refill; palpate for presence/absence and quality of pulses. Calculate ankle-brachial index (ABI), as appropriate.

Determine usual voiding pattern; compare with current situation.

Collaborative:

Administer medication as indicated.

Result less than 0.9 indicates need for more aggressive preventive interventions to manage.

For proper overview of the infant’s condition.

To promote further improvements to the infants condition.

By: Syra Allison Dimco

PATHOPHYSIOLOGY OF NEWBORN HYPOTHERMIA

Precipitating Factors Predisposing factors

Environmental factors -sick babies-Convection -normal term babies-Convection -preterm babies-Radiation -low weight babies-Evaporation

Immature Thermoregulation

Heat transfer

Decrease body temperature

Non shivering thermogenisis, vasoconstriction, increase metabolic rate

Increase thermal insulation

Further decrease in temp.

S/Sx

By: Marycris A. Pagapula-an

Depletion of glycogen stores

Circulatory-acrocyanosis-cool, pale extremities-hypoxia-slow capillary refill

Neuro. -lethargy

Metabolism of brownfat

O2

consumption/ demand

Depletion of brownfat

Decrease surfactant production

Increase use of glycogen

Lymphatic-metabolic acidosis

Respiratory-apnea-dyspnea-Tachypnea-increase respiratory rate

Cardio.-tachycardia

Endocrine-hypoglycemia

NURSING CARE PLAN

Problem Identified: Chilling

Nursing diagnosis: Risk for altered body temperature r/t immature compensation to environmental factors 20 newborn hypothermia

Cause Analysis: The preterm newborn has a great deal of difficulty attaining body temperature because she has a relatively large surface area per kilogram of body weight. In addition, because the infant does not flex the body well but remains in an extended position. Rapid cooling from evaporation is likely to occur.

CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective:

Objective: Lethargic acrocyanosis Capillary refill time of 3

seconds. Apnea cool pale extremities dry skin Temperature: 35.5 C Tachycardia Dyspnea RR:68 bpm

STO:

Within 30 min of wrapping the infant with warm blanket, cover the infants head, maintaining thermal neutral environment such as turning off the air-conditioned there will be a decrease of heat loss through conduction, convection, radiation, & evaporation

LTO:

Within 2 hour of providing the use of incubators, radiant warmer, and skin-to-skin contact the body temperature 35.5C will maintain to its normal range from 36.5-37.5

Independent: Rub both hand before touching

the newborns body

Wrap infant snugly in a warmed blanket or provide skin-to-skin contact.

Place infant in a preheated environment (under radiant warmer).

Place infant on a padded, covered surface.

Monitor axillary temperature at least every 8 hours; more frequently for infants at high risk.

Postpone bath if there is any question regarding stabilization of body temperature.

Dress infant in a shirt and diaper and swaddle in a blanket or cover

To decrease the possibility of heat loss through conduction.

Helps conserve heat in the body

Maintains thermoneutral environment, helps prevent cold stress.

To maintain stable body temperature and decrease the possibility of heat loss through conduction.

Regular temperature monitoring will identify adequate or inadequate thermoregulation. Axillary temperature is good indicator of newborn’s surface temperature

Bathing the infant can cause heat loss through evaporation.

To prevent from chilling and decrease the possibility of heat loss through convection.

STO:

After 30 min of wrapping the infant with warm blanket, cover the infants head, maintaining thermal neutral environment such as turning off the air-conditioned there is a decrease of heat loss through conduction, convection, radiation, & evaporation

LTO:

After 1 hour of providing the use of incubators, radiant warmer, and skin-to-skin contact the body temperature 35.5C will maintain to its normal temperature range from 36.5-37.5

with blanket.

Cover the infants head

Keep infant away from drafts, air conditioning vents, or fans.

The infant’s head provides a large surface area for heat loss

To maintain stable body temperature of the newborn and decrease the possibility of heat loss through conduction, convection, radiation, & evaporation

Reference: Wong’s Nursing Care of Infants and Children Vol.1 & 2

Problem Identified: Chilling

Nursing diagnosis: Ineffective thermoregulation r/t decrease subcutaneous body fat 20 newborn hypothermia

Cause Analysis: The preterm infant has little subcutaneous fat for insulation and poor muscular development does not allow the child to move actively as the older infant does to promote heat. The preterm infant also has limited amount of brown fat; special tissue present in newborns to maintain body temperature. (Maternal and Child Health Nursing, 4th Ed. By Pillitteri,)


Subjective:

Objective: Lethargic acrocyanosis Capillary refill time of 3

seconds. Apnea cool pale extremities dry skin Temperature: 35.5 C Dyspnea RR:68 bpm

STO:Within 30 mins. of mummifying the infant, maintaining thermal neutral environment such as turning off the air-conditioned, monitoring the axillary temperature as necessary body will minimize heat loss, warm, and dry skin

LTO:

Within 2 hour of providing the use of incubators, radiant warmer, and skin-to-skin contact the body temperature 35.5C will maintain to its normal range from 36.5-37.5

Independent: Monitor axillary temperature at

least every 3 hours or as necessary.

Provide heat/warm the newborn using incubators, radiant warmer, and skin-to-skin contact.

Maintain thermal neutral environment and avoid situations that might predispose the infant to heat loss, such as cool air, drafts, bathing, and cold bedding.

Dry newborn thoroughly and quickly and discard the wet blanket. Place the infant under a pre warmed radiant warmer.

Avoid placing infant on cold surface or using cold instrument in assessment.

Ambient temperature of the room where the newborn is kept should be monitored

Regular temperature monitoring will identify adequate or inadequate thermoregulation. Axillary temperature is good indicator of newborn’s surface temperature

To warm the newborn and adequately maintain accepted thermal range

To maintain stable body temperature of the newborn and decrease the possibility of heat loss through conduction, convection, radiation, & evaporation

Drying quickly and placing and placing on a warm, dry surface prevent heat loss from evaporation.

Cold surface and instrument increase heat loss by conduction

To prevent excessive cooling.

STO:After 30 mins. of mummifying the infant, maintaining thermal neutral environment such as turning off the air-conditioned, monitoring the axillary temperature as necessary the body minimize heat loss, warm, and dry skin

LTO:

After 1 hour of providing the use of incubators, radiant warmer, and skin-to-skin contact the body temperature 35.5C maintain to its normal temperature range from 36.5-37.5

Mummify and use thick blankets to cover the patient

Teach the mother about the infant’s need for warmth and to keep the infant’s head covered

Teach family members about:

-signs and symptoms of altered body temperature, such as cool extremities.

-factors in home that contribute to neonatal heat loss and ways to minimize heat loss

-importance of contacting a health care provider when problems related to temp regulation

Helps conserve heat in the body


Careful teaching allows family members to take an active role in maintaining the neonate’s health.


Problem Identified: difficulty of breathing

Nursing diagnosis: Ineffective breathing pattern r/t decrease production of lung surfactant 20 to newborn hypothermia

Cause Analysis: A newborns lung is structurally underdeveloped for postnatal life. To add, the premature delivery and the inadequate pulmonary surfactant. A deficiency in surfactant, which functions to decrease the surface tension within the alveoli. Without surfactant, the infant experiences decreased pulmonary compliance, ventilation perfusion mismatching, and significant increase in the work of breathing. Gelli’s and (Kagan’s Current Pediatric Therapy by Burg Ingelfinger p. 261)


Subjective:

Objective: RR:68 bpm Lethargic acrocyanosis Capillary refill time of 3

seconds. apnea cool pale extremities dry skin Temperature: 35.5 C dyspnea

STO:

Within 30 minutes of positioning the infant to the right side, suction mouth and nasopharynx with bulb syringe as needed RR will decrease from 68- 63bpm

LTO:

Within 1 hour of administering oxygen as ordered RR will be in the normal range of 30-60bpm and manifest an increase in oxygenation as evidenced of normal skin color, pinkish mucosa, good capillary refill and good breathing pattern.

INDEPENDENT: Monitor/ assess RR as

necessary.

Suction mouth and nasopharynx with bulb syringe as needed.

Maintain optimal body temperature by mummifying the infant.

Avoid constricting clothing or bedding

Position infant on right side after feeding.

Check child's position frequently.

Collaborative:

Administer oxygen as ordered via nasal cannula or mask .

assessment provides information about neonate’s ability to initiate and sustain an effective breathing pattern

May be necessary to maintain airway patency especially in infant receiving controlled ventilation.

Even a slight increase or decrease in environmental temperature can lead to apnea.

To facilitate breathing

to prevent aspiration.

to ensure child does not slide down to avoid compressing the diaphragm.

Facilitates proper oxygen in the blood.

STO:

After 30 minutes of positioning the infant to the right side, suction mouth and nasopharynx with bulb syringe as needed RR decreases from 68- 63bpm

LTO:

After 1 hour of administering oxygen as ordered RR is in the normal range of 30-60bpm and experience no apnea.


Problem Identified: Ineffective tissue perfusion

Nursing diagnosis: Ineffective tissue perfusion r/t decrease O2 saturation in the blood 20 newborn hypothermia

Cause Analysis: Decrease resulting in the failure to nourish the tissues at the capillary level. Reduced arterial blood flow causes decreased nutrition and oxygenation at the cellular level. (Maternal and Child Health Nursing, 4th Ed. By Pillitteri,)


Subjective:



STO:

Within 1-2hrs of giving nursing intervention such as checking peripheral pulses every 4 hrs, elevate the head of the bed 30 degrees to promote circulation to lower extremities the peripheral pulses will remain present.

LTO:

Within 5hrs of administering supplemental oxygen as ordered the pt. will experience adequate tissue perfusion and cellular oxygenation.

Independent:

Assess for possible causative factors related to temporarily impair arterial blood flow.

Monitor pulses for rate, rhythm and capillary refill time.

Elevate the head of the bed 30 degrees.

Position neonate to the right side.

Check child's position frequently.

Maintain environmental and body warmth without overheating.

Note changes in level of consciousness (seizures activity) development of sensory/motor deficit.

Early detection of cause facilitates prompt, effective treatment.

Assessment is needed for ongoing comparisons; loss of peripheral pulses must be reported or treated immediately.

To promote circulation to lower extremities,

This promotes optimal lung ventilation and perfusion. The patient will experience optimal lung expansion in upright position.

To ensure child does not slide down to avoid compressing the diaphragm.

Prevents vasoconstriction and air in maintaining circulation and perfusion.

Changes may reflect eliminated perfusion in the CNS.

STO:

After 1-2hrs of giving nursing intervention such as checking peripheral pulses every 4 hrs, elevate the head of the bed 30 degrees to promote circulation to lower extremities the peripheral pulses remain present.

LTO:

After 5hrs of administering supplemental oxygen as ordered the pt. experience adequate tissue perfusion and cellular oxygenation.

Collaborative:

Monitor Oxygen saturation (e.g. pulse oximeter)

Administer oxygen as ordered via nasal cannula or mask.

To determine oxygen supply in the body.



Problem Identified: Hypotension

Nursing diagnosis: Decrease cardiac output r/t vasoconstriction 20 newborn hypothermia

Cause Analysis: Constriction of the peripheral blood vessels will alter the flow of blood to perfuse the different cells of the body. (Maternal and Child Health Nursing, 4th Ed. By Pillitteri,)


Subjective:



STO:

Within 3-4 hrs of rendering effective nursing interventions such as provide pre-warm blanket, keep the baby covered at all times and put the baby under radiant warmer the skin will remain warm and dry.

LTO:

Within 5-8hrs of rendering effective nursing interventions such as administering supplemental oxygen as ordered the cardiac status will be stabilize and will maintain adequate cardiac output.

Independent:

Monitor the neonate’s body temperature.

Note skin or pallor, cyanosis.

Observed skin color, moisture, temperature, and capillary refill time.

Keep the baby out contact with cold surfaces.

Keep the baby covered at all times possible. Use a pre warmed blanket.

Put the baby under radiant warmer when temperature indicates

Cover infant’s head.

Collaborative:

Monitor Oxygen saturation (e.g. pulse oximeter)

To determine the need for intervention and the effectiveness of therapy.

Pallor is indicated of diminished peripheral perfusion and decrease cardiac output.

Presence of pallor: cool, moist skin; and delays capillary refill time may be due to peripheral vasoconstriction.

Baby will transfer body heat to a cooler surface.

This decreases the convection heat loss.

To warm the newborn and adequately maintain accepted thermal range


To determine oxygen supply in the body.

STO:

After 3-4 hrs of rendering effective nursing interventions such as provide pre-warm blanket, keep the baby covered at all times and put the baby under radiant warmer the skin remains warm and dry.

LTO:

After 5-8hrs of rendering effective nursing interventions such as administering supplemental oxygen as ordered the cardiac status was stabilize and will maintain adequate cardiac output.

Administer oxygen as ordered via nasal cannula or mask.



By: Marycris A. Pagpapula-an

References: Internet:http://family.go.com/parentpedia/baby/milestones-development/baby-grasping/

http://www.babyworld.co.uk/information/pregnancy/glossary/a.asp

http://www.rwjuh.edu/health_information/centers_pregnancy_lvl2hrn.html

http://allnurses.com/general-nursing-student/newborn-nursing-diagnosis-346647.html

http://books.google.com.ph/books?id=bsiO_GbZpgYC&pg=PA122&lpg=PA122&dq=newborn+hyperthermia&source=bl&ots=RhByQOaxUp&sig=nkP-3r7ci4_q8C0b59JkS0Hbdq0&hl=tl&ei=H3skS4-yJZeXkQWosrSnAw&sa=X&oi=book_result&ct=result&resnum=6&ved=0CCQQ6AEwBTge#v=onepage&q=newborn%20hyperthermia&f=false

http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/MSM_97_2/en/

http://books.google.com.ph/books?id=bsiO_GbZpgYC&pg=PA122&lpg=PA122&dq=newborn+hyperthermia&source=bl&ots=RhByQOaxUp&sig=nkP-3r7ci4_q8C0b59JkS0Hbdq0&hl=tl&ei=H3skS4-yJZeXkQWosrSnAw&sa=X&oi=book_result&ct=result&resnum=6&ved=0CCQQ6AEwBTge#v=onepage&q=newborn%20hyperthermia&f=true

BooksMaternal Newborn Nursing a Family Approach By: Sally B. Olds Marcia L. LondonPatricia A. Ladwig

Nurse's Pocket Guide Edition 11 By: Marilynn Doenges Mary Frances Moorhouse, Alice C. Murr

Focus on PathophysiologyBy: Barbara L. bullock, reet L. henze

Essentials of Maternity and NewbornBy: Scott Ricci




http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/MSM_97_2/en/




http://allnurses.com/general-nursing-student/newborn-nursing-diagnosis-346647.html

http://www.rwjuh.edu/health_information/centers_pregnancy_lvl2hrn.html

http://www.babyworld.co.uk/information/pregnancy/glossary/a.asp

http://family.go.com/parentpedia/baby/milestones-development/baby-grasping/

Newborn Hypothermia and Hyperthermia(Final Copy)

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Transcript of Newborn Hypothermia and Hyperthermia(Final Copy)