0% found this document useful (0 votes)
12 views19 pages

New Born Care

immediate care of newborn baby

Uploaded by

suvangisaha5
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
0% found this document useful (0 votes)
12 views19 pages

New Born Care

immediate care of newborn baby

Uploaded by

suvangisaha5
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 19

Tripura institute of paramedical sciences, Nursing

Subject: child health nursing- i

Care plan ON: - HIGH RISK NEWBORN (PRETERM BABY)

Date of submission: 22/07/2024

SUBMITTED TO- SUBMITTED BY-

Ms. ANUPA MALAKAR Ms. SUVANGI DEY


(ASSO. PROFESSOR) M. SC NURSING, 2nd SEMESTER.
HOD, of Child Health Nursing ROLL NO- 06
TIPS, NURSING TIPS, NURSING

INTRODUCTION:
As per my clinical posting I was posted in NICU ward at IGM Hospital. During
my clinical posting I came across a baby suffering from feeding problem, low
birth weight, respiratory distress. Docter diagnosed the baby as preterm baby,I
have taken this case for my care plan and given care for 3 days.

BASELINEDATE/GENERALINFORMATION:

Child’s Name: B/O Mousami Biswas


Age: D4
Sex: Female Child

A.R No: 198/24

Ward: NICU Ward

Address: Durga Chowmahani, P.O- Ramnagar, P.S- Ramnagar.

Father’s Name: Bijon Bin

Mother’s Name: Mousami Biswas

Religion: Hinduism

Father Occupation:

Monthly Family Income: Rs.20000/month approx.

Date of Admission: 26/06/2024 at 11.45 pm

Name of Doctor: Dr. Rajat Debbarma

Informant’s Relationship to Child: Child’s mother and father

Language: Bengali

Developmental Age: Neonate

CHIEF COMPLAINTS WITH DURATION:


My patient B/o Shilpi Bhowmik admitted in GBP hospital on 11/11/2023 at 10 AM with the chief complaints of
high temperature, refusal of breast feeding and poor sucking last 3 days.

HISTORY OF PRESENT ILLNESS:


HISTORY OF PAST ILLNESS:
Significant Medical History: My patient doesn’t have any significant past history except common cold and
fever.

Significant Surgical History: My patient doesn’t have any past surgical history.

BIRTHHISTORY:
Antenatal history
Mother has taken proper nutrition during the antenatal period. She is a primi
gravida mother. She has done regular antenatal checkup. She received 2 doses of
TT. Mother’s USG is done. The mother has taken proper amount of iron and folic
acid tablet. Nothing significant was found. There is no history of any exposure to
teratogenic (drugs, +infection, addiction). There is no significant complication.

Natal history
The mother delivered the child by Normal vaginal delivery. The child cried
immediately after birth. At the time of birth, the child’s 1min APGAR score was
7, and 5min APGAR score was 9. The child was born at IGM Hospital. The
weight of the baby is 3.1 kg. The Condition of neonate is normal and there is
absence of any congenital abnormality.

Post-natal history

Condition of mother and child is good. The child is initiated breastfeeding within
2 hours after birth, the child sucks properly.

IMMUNIZATION HISTORY:

DIETARY HISTORY:
The baby has got proper breastfeeding after 2 hours of birth.
PERSONAL HISTORY

SLEEPING:
Duration of sleeping: 14-16 hours/day
Problems related to sleep: The baby sleep doesn’t sleep much at night.

ELIMINATION:
No. of urine frequency: 8-9 times/day
No. of bowel movements: 3-4times/day
Toilet trained: Not yet started.
Problems related to elimination: Does not have any problems related to elimination. Baby has
passed meconium

BEHAVIOUR:

Problems: The baby has no problem.

Conduct disorders: The baby doesn’t have any conduct disorders.


Play: The baby is moderately active and too small to do play activity.
PERSONAL HYGIENE:
Oral hygiene: Good oral hygiene is maintained by her
mother.
Bath: The baby was wiped out and cleaned 1time a day by her
grandmother.

FAMILY HISTORY
Type of family: Nuclear Family

No. of members in the family: 05 members

Socio-Economic history:
Father of the child is the only earning member of the family, monthly income is
10000/month approx. they live in kacha house but well ventilated. They get water from
tubewell. Electricity is available. They dispose waste by dumping method.

ASSESSMENT OF GESTATIONAL SCORE/BALLARD


SCORES:
PHYSICAL MATURITY:
1 -1 0 1 2 3 4 5 Record
Score
Below
Smooth
Pink,
Skin 1
Visible
Veins
Lanugo Thinning 2
Creases
Planter over
4
surface entire
sole
Raised
areola
Breast 3-4 4
mm
bud
Formed
Eye and & firm
3
Ear instant
recoil
Majora 4
cover
Genitals
clitoris Total
(Female)
& score=18
minora
NEUROMUSCULAR MATURITY:
NEUROMUSCULARMATURITY SCORE SIGN
SIGN
-1 0 1 2 3 4 5 SCORE

Posture
4

Squar
e
Windo 4
w

Arm Recoil
4

Popliteal
Angle 3

Scarf Sign
3

Heel To Ear
2

TOTAL SCORE = 38.


Therefore, the gestational age is 38 weeks.
PHYSICALASSESSMENT:
Vital Signs:
Date: 9/06/2024

SL VITALSIGNS FOUNDINCHILD NORMAL REMARKS


NO. VALUE
01. Temperature 99.10F 97.4-99.50F Normal

02. Heart Rate 140 Beats/min 120-140 Normal


beats/minute
03. Respiration 49 breaths/min 30-60 Normal
breaths/min

i. Anthropometric Measurements:
SL PARAMETERS FOUNDIN NORMAL REMARKS
NO. CHILD VALUE
01. WEIGHT 3.1 kg 2.5-3.9kg Normal
02. LENGTH 51 cm 48-52cm Normal
03. HEAD 33cm 33-37cm Normal
CIRCUMFERENCE
04. CHEST 31.5 cm 30-33cm Normal
CIRCUMFERENCE

PHYSICAL EXAMINATION: -
General appearance: -
Appearance: Appearance of the child is looking normal and the child is active.
Body built: Baby’s body building is well nourished.
Posture: Normal frog like position.
Foul body odor: Baby have not any type of foul body odor.
Foul breath: The baby has not any foul breath.

Skin condition: -
Skin color: The baby skin is pink in color.
Temperature: 99.1ºF
Texture: skin is soft in texture
Turgor & elasticity: The baby’s skin turgor and elasticity are normal and present. Vernix caseosa is
present throughout the body.
Edema/puffiness: The body of the baby is not edematous.

Head & Face: -


Shape: shape of head is normal
Hair: silky and black are evenly distributed in the head but slightly sticky
Fontanels: Anterior fontanel is present is diamond shape, no bulging or depression is present.
Posterior fontanel is present in triangle shape.
Absences of cephalohematoma / caput succedaneum.
Facial Appearance: facial appearance is normal
Cyanosis: Cyanosis is absent in the baby’s face.
Tenderness: There is no tenderness in her face.
Eyes: -
Eyebrows: The eyebrows are symmetrically distributed.
Eyelashes: Eyelashes are black in color and is distributed equally.

Eyelids: Eyelids are normal, and edematous.

Shape & appearance of eyes: Eyes are normal, paleness is absent.

Sclera: Sclera is white in color, clear.


Conjunctiva: Conjunctiva is normal with absences of any discoloration.
Cornea: Cornea is clear.
Pupils: The baby’s pupils are normal, reacting to light.

Vision: Baby can see nearby objects clearly.

Squint eye: There is absent of squint


eye.
Ears: -
Position: Tip of the pinna and outer canthus of eye is in straight-line.
Shape & size: The size of the ears is normal and shape of the baby’s ear was well
curved and instant recoil.
Hearing: the baby turns head with the sounds.

Nose:-
External
nose:
Size and position: The size of the baby’s nose is normal and position is has seen midline.
Shape: Normal in shape not deviated.
Internal nasal mucosa: Spiral shaped with proper mucosal folds.

Mouth:-
Lips: Normally structured and dark pink in color.
Dryness of lips: dryness of lips is not present.
Tongue: All taste buds are normal, oral thrush is absent.
Oropharynx: The oropharynx is seen in normal.

Neck:-
Range of motion: The baby’s neck is easily moveable.
Lymph node: Lymph nodes are palpable.
Skin fold: there is absent of extra skin fold in neck of the baby.

CHEST:-
Respiratory rate: 60 breaths /min.
Rhythm: The rhythm is normal.
Shape: The shape of the chest is normal.
Chest wall movement: Chest drawing is absent.
Lung auscultation: lung auscultation is clear with no murmur sound present.
Breast& axilla: Breast is normal. Witches milk is present

Heart:-
Heart rate: 134 beats/ min
Heart sound: S1 and S2 sound heard normally, wheezing sound is absent.

Abdomen: -
Inspection: -
Shape: Cylindrical shape.
Scar: Scar marks is absent.
Lesions: Any type of lesions is absent.
Size: There is present of abdominal distension.
Umbilicus: No abnormality was found, discharge or any type of infection is present in the umbilicus.
Two arteries and one vein are visible.
Palpation: -
Liver: The Soft and normally palpable.
Spleen: The spleens of the child is normal.
Tenderness: Soft and non-tendered.
Auscultation: Bowel sound is present.
Genitalia: -
Female genitalia: Labia majora and labia minora is well developed. Labia majora
covered labia minora and clitoris.
Discharge: Vaginal discharge or pseudo menstruation is not present. Absent of any
lesions.
Back: -
Vertebral column: Normal, congenital malformation is absent. Absences of any type of spinal
curvature.

Buttocks: Absent of any malformation. Mongolian spot is present. Rectal opening present

Extremities: -
Condition of nails: Condition of nails is good and clean. No sign of cyanosis. Capillary refill normal.
Angle of nails beds: The angle of nail bed soft, and proper in shape, there is absent of
any nail deformity.
Nail bed color: The color of nail bed is normal, pinkish.

Upper extremities: -

Range of motion: Full range of motion is normal and can performed.


Syndactyl: The baby is not having any fused or webbed fingers.
Polydactyl: The baby is not having any extra fingers.
Clubbing of fingers: There is absent of clubbing fingers.
Lower extremities:
Length of leg’s: Symmetry in length of both legs.
Range of motion: Full range of motion is normal and can performed.
Syndactyl: The baby is not having any fused.
Polydactyl: The baby is not having any extra fingers.
Webbing of fingers: There is absent of webbing fingers in baby’s body.
Clubbing of fingers: There is absent of clubbing of fingers.

REFLEXES:
REFLEX POSITION STIMULATION RESPONSE
Rooting Supine The corner of the baby’s Baby turns her head and open
mouth is stroked or touched her mouth to follow the
direction of the stroking.
Sucking Supine Mother gives breast feeding Starts sucking the nipple
vigorously.

Swallowing Supine Accompanies with sucking Breast milk is swallowed.


reflex.
Sneezing Supine Irritation or obstruction in air Mother said the baby is able to
and passages. sneeze and cough.
coughing

Extrusion Supine When tongue is depressed by a The baby forced the tongue
spoon of baby. outwards.
Gag Supine Stimulation of posterior Baby’s gags immediately.
pharynx by food.
Glabellar Supine Tapping brisky on glabella of Baby is immediately closed her
baby. eyes tightly.
Blinking Supine When flash of light is in the The baby closes her eyes
eyes of the baby spontaneously.
Pupillary Supine Bright light shines towards Pupil constricts.
pupil of the baby.
Doll eye Supine When I move the head to right The baby’s eyes lag behind and
or left of the baby slowly adjust to new position of
head.
Palmer grasp Supine Placing my index finger in the Flexion of fingers and fist
palm of the baby. making.
Planter grasp Supine Pressing the thumb against Flexion of toes is seen in the baby.
the sole just behind the toes
in the foot of the baby.
Moro reflex Supine In response to sudden touch, Sudden extension abduction of
the baby throws back the head, extremities and fanning of fingers
extends the arms and legs, with index finger and thumb
cries and then pulls the arms forming a C shape followed by
and legs back in. flexion and abduction of
extremities. Then child cry.
Tonic neck reflex Supine Rotation of baby’s head to one Extension of the extremities on
side the chin side and flexion of those
on the opposite side.

Stepping/ Holding When the sole of the baby’s This reflex is not seen in the
walking upright feet touches a flat surface. baby yet.
/dancing
Babinski reflex Supine Striking along the lateral Simultaneous dorsi flexion of
aspect of the sole extending great toe and fanning of other toes.
from heel.

NURSINGMANAGEMENT:
ASSESSMENT:

 Assess the birth history and physical examination.

 Assess the vital signs and recorded.


 Monitoring breastfeeding process and educate the mother about exclusive
breast feeding.
 Educate caregiver about respiratory infection and umbilical infection.
 Assess the child for maintaining body temperature.
 Assess intake and output
 Educate the caregiver about the maintenance of warm, well-
ventilated environment.
 Educate the care giver about burping technique ant its importance.
 Educate care giver about proper clothing for the baby
 Educate about hand washing and proper hygienic measures.
 Encourage the child’s parents to follow up the medical care.
 Educate caregiver about the proper vaccination.

NURSINGCAREPLAN:
Diagnosis:
1. Ineffective airway clearance related to excess mucous, improper suctioning or
positioning.
2. High risk for ineffective thermoregulation related to immature temperature control,
change in environmental temperature.
3. High risk for infection or inflammation related to deficient immunologic defenses,
environmental factor, and maternal disease.
4. Risk for imbalanced nutrition less than body requirement related to immaturity, parental
knowledge deficit and ignorance.
5. Risk for impaired family process related to maturational crisis, birth of term infant,
changing family unit.
NURSINGCAREPLAN:
DIAGNOSIS GOAL PLANNING IMPLEMENTATION EVALUATION
1. Ineffective To - Suctioned the mouth and -Airway remains
-Suction the mouth
airway maintain and nasopharynx nasopharynx with bulb patent and
clearance a patent properly. syringe as needed. respiratory rate is
related to excess
airway. - provided appropriate with in normal limit.
mucous, - To provide
improper appropriate position position of the infant on
suctioning or of the infant. right side after feeding to
positioning. prevent aspiration.
- Monitor vital signs
frequently. - Monitored vital signs
frequently.
- To assess the signs - Assessed the signs of
of respiratory respiratory distress like
distress. tachypnea, abnormal breath
sound and cyanosis.

2. High risk for To -Assess the body -Assessed the body Newborn is
ineffective maintain temperature and temperature and maintained stable
thermoregulatio stable room temperature. room temperature. body temperature.
n-n related to Temperature–370C
body Temperature–370C
immature -Keep the infant in a
temperature temperatu preheated -Kept the infant in a
control, change re-re. environment like preheated environment like
in radiant warmer. radiant warmer.
environmental -Wrapped the baby in
-Wrap the baby in
temperature. double layered pre-
double layered
pre-warmed cloth warmed cloth with head
with head covered with cap.
covered with cap. - Avoided unnecessary
- Avoid unnecessary exposure of neonate
exposure of neonate during examination.
during examination. - Removed wet diapers and
- Remove wet clothing promptly.
diapers and clothing - Maintained room
promptly. temperature between 240C
- Maintain room – 250 C.
temperature
between240C–250C.
DIAGNOSIS GOAL PLANNING IMPLEMENTATION EVALUATION
3. High risk for To -Assess signs of -Assessed signs of infection Risk for infectionis
infection or minimize infection spontaneously. minimized.
inflammation risk for spontaneously.
related to -Maintained aseptic technique
infection -Maintain
deficient during any procedure.
immunologic aseptic technique
during any -Initiated exclusive breast
defenses,
environmental procedure. feeding.
factor, and -Assessed cord daily for odor,
maternal disease. -Initiate
exclusive breast color and drainage.
feeding. - Washed hands before and
after carrying for each infant.
-Assess cord daily
- Restricted visitors
for odor, color
unnecessarily.
and drainage.
- Wash hands
before and after
carrying for each
infant.
4. Risk for To -Initiate exclusive -Initiated exclusive breast New born received
imbalanced maintain breast feeding as feeding as soon as possible. adequate feeding and
nutrition less optimum soon as possible. exhibits no signs of
than body nutrition. -Taught the mother about the
-Teach the mother technique of breast feeding. poor feeding.
requirement
related to about the
technique of -Watched for poor feeding,
immaturity, lethargic, aspiration etc.
parental breast feeding.
knowledge -Watch for poor -Placed the infant on right side
deficit and feeding, lethargic, after every feeding.
ignorance. aspiration etc. -Educated the mother to do
-Place the infant on burping the infant after each
right side after feeding.
every feeding.
-Educate the
mother to do
burping the infant
after each
feeding.
DIAGNOSIS GOAL PLANNING IMPLEMENTATION EVALUATION
5. Risk for To -Keep the child -Kept the child close to Maintained parent
impaired family maintain close to the mother the mother to maintain infant attachment
process related parent to maintain mother mother child bonding. behavior by the
to maturational infant child bonding.
-Encouraged the parents to parents and family
crisis, birth of attachme
-Encourage the see and hold the infant as members
term infant, nt
parents to see and soon as possible. demonstrate ability
changing family behavior.
hold the infant as to provide newborn
unit. -Encouraged rooming in.
soon as possible.
care.
-Encourage -Involved the family
rooming in. Members in childcare.
-Involve the -Taught the parents about the
family members temperature maintain, breast
in child care. feeding, signs of infection
-Teach the and immunization.
parents about the
temperature
maintain, breast
feeding, signs of
infection and
immunization.
HEALTHEDUCATION:
Breastfeeding:

 Advice mother to breastfeed the baby every two hourly or whenever hungry.
 Tech the mother breastfeeding technique.
 Advice mother to clean nipples with soft cloth and lukewarm water after and before feeding
 Advised the child’s mother to give the child exclusive breastfeeding up to 6months.
Providing warmth:

 Advised the baby’s mother to keep the baby clean and warm.
 Advice the mother to keep the head, hands and legs of the baby covered.
 Advice and teach mother how to rap the baby to provide warmth.

Vaccination:
 Importance of immunization and vaccination is explained to mother.

 Advised the mother to take immunization as per the immunization scheduled to


her baby.

Regarding Personal Hygiene: -

 Advised the baby’s mother to maintain proper hygiene during handling the baby.

 Advice mother to clean the eyes of baby once every day using clean cloth and lukewarm water.

 Advice mother that the umbilical cord should be kept open and dry without applying any
dressing
 Advised the baby’s mother to cut the nails of the baby and clean her baby’s
body and always wear clean clothes to her baby.

Follow-up Care:
 Advise the mother to bring the baby in hospital to visit and follow up care as per
doctor’s advised.
 Advice mother to bring the baby for immunization.
SUMMARY:
After assessing all the physical examination, vital signs, anthropometric measurement,
Ballard score and reflexes the findings reveals that the baby is fulfilled all the
characteristics of a normal new born baby.
BIBLIOGRAPHY:

1. Padmaja. A. “Textbook of child health nursing”. 1 st edition. New Delhi: the health sciences
publishers; 2016.p.529.
2. Pal. P. “Textbook of pediatric nursing”. 1st edition. New Delhi: Paras medical publishers;
2016. p. 135.
3. Datta. P. “Pediatric nursing”. 3rd edition. New Delhi: Jaypee brothers’ medical
publishers; 2014.p. 66.

4. Sharma. R. “Essentials of Pediatric Nursing”. 3 rd edition. New Delhi: Jaypee Brothers medical
publishers; 2016. p.221.

5. Gupta. P. “Essential pediatric nursing”. 3rd edition. New Delhi: CBS publishers; 2014.

6. Magon. Dr. P. “Textbook of child health nursing”. New Delhi: Lotus publishers; 2022.p.111.

You might also like