New Born Care
New Born Care
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:
Religion: Hinduism
Father Occupation:
Language: Bengali
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:
FAMILY HISTORY
Type of family: Nuclear Family
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.
Posture
4
Squar
e
Windo 4
w
Arm Recoil
4
Popliteal
Angle 3
Scarf Sign
3
Heel To Ear
2
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.
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: -
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.
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:
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 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.