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suction bulb, tactile stimulation, neo present at delivery___________________________ Ilotycin 22.15 (time) Vit K 22.15 (time) Nursed in L&D: Yes After you have read the infants chart and gathered the information, give your assessment of this infants status when it was 1 hour after birth (give details, not good) Vital signs were stable and within normal limits. Heart Rate: 148, 132, 128. Temperature: 37.0, 36.8, 36.0. Respirations: 56, 52, 50. Respiratory, cardiovascular, neuro, and skin assessments revealed no positive findings. No bowel movements or voids were recorded in the first hour.
NOW YOU ARE READY TO DO A PHYSICAL ASSESSMEDNT ON THIS BABY (to be completed by you the day you are caring for the baby): Temp 36.9 Color: Pink Jaundice + HR 112 Resp 59 + Pale Mottles Plethoric Retracting Dry +
Stained
Acrocyanosis
Abrasions Milia
Nevi
Lanugo
Vernix +
Respirations: Regular
Grunting
Shallow
Shrill
Sighing
Other
Cry: Lusty
Head: Symmetry/shape Bilateral symmetrical/elongated Molding Cephalhematoma ISE mark Full Full + Abnormal Other
Caput succedaneum
Anterior fontanel: Flat + Posterior fontanel: Flat Sutures Coronal Sagittal Lambdoidal +
Depressed Depressed
Overriding
Separated
Ears: (describe exact location & how you determined if it was normal) Position: Normal Skin tags _____ + Flaring Patent: Left + Right Subconjunctive hemorrhage Nevi on lids Edema Red reflex Other NA + Pale Right +__ Left ___ ___ ___ NA_ ___ Cyanotic Describe normal position Top of ears
Nose: Symmetry
Eyes: (describe what you found) Align with top of ears. Symmetrical.
Abnormal Abnormal
Lips: Cleft
Drooping
Symmetry
Shape Round
Fracture +
Engorgement NA +
Other
Time
Color of urine
NA
Female: Labia majora: Completely covers minora NA Partially covers minora Labia minora protruding NA Vaginal discharge + + Truft of hair Intact Type Other Left + + 5/5 + + + Dislocated/subluxation + Meconium Posterior: Pilonidal dimple Spinal column: Symmetry Anal patency Yes Anterior Abd: Symmetry Cord: # of vessels Extremities: Right Symmetry Movement Digits (number) Flexion creases Palmar creases Sole creases Hips: Intact Right Left + + + + 5/5 + + + 3
Stool Yes
Protruding base
Lethargic Tremors
Reflexes: Reflex: Describe what you observed Rooting: Turn head towards light touch on cheek Sucking: Sucking movement of mouth Moro: Rapid abduction & extension of arms/embracing motion Stepping: Stepping motion of legs Grasp/hand: Curls fingers Grasp/foot: Curls toes Describe the procedures Stoke cheek Place finger in mouth Pick up baby and carefully drop back onto hands/surface Pick up baby vertically and place feet on surface Put finger in palm of hand Put finger on bottom of foot What is your overall assessment and prognosis for this infant (do not say good): Overall this baby seems to be in good health. He has normal vital signs and his reflexes are appropriate for his developmental age. No abnormalities were discovered on this assessment. This infant should continue to grow and thrive, based on assessment results. Describe normal responses Turn head towards stimulus Suck on finger Rapid abduction & extension of arms & embracing motion Pick up legs and make stepping motion Curl fingers around finger Curl toes around finger
On the basis of your assessment, list at least TWO nursing diagnosis for this baby and all the teaching interventions you would use for each nursing diagnosis. Please include the rationale for your actions. You must have at least two references besides your textbooks for your rationales. Be sure your assessment and interventions correspond to your Nursing Diagnosis.
Nursing Diagnosis Risk for imbalanced nutrition less than requirements r/t ineffective breastfeeding
Necessary Assessments/Interventions Assist parents in identifying infant arousal cues as opportunities to practice breastfeeding Monitor voids and stools Measure daily infant weights Refer mother to lactation consultant as appropriate
Rationale It is important for newborns to receive adequate nutrition soon after birth and throughout life. Breast milk contains everything that a newborn needs. According to the School of Nursing and Midewifery at the University of Western Sidney, a womans breast milk has a unique composition of nutrients, enzymes, growth factors, hormones, and immunological and antiinflammatory properties that can reduce the risk of a wide range of illnesses for a child well beyond infancy. Essentially, it is like liquid gold for a growing baby (Burns, Schmied, Fenwick, & Sheehan, 2012, pp. 1737). Ineffective breastfeeding could cause delayed growth and other complications for newborns.
Apply cap to prevent heat loss Keep umbilical cord dry by exposing to air and diapering newborn below cord Respond to newborns cues for care to facilitate development of trust Keep infant with parents after birth when possible
Newborns must go through a transition period after birth where they rapidly make physiological changes to adapt to the environment. According to the American Journal of Nursing, there are six stages of transition. It is important for nurses to assure that steps 3-6 occur. These include the initiation of air breathing and respiration, the change from fetal to neonatal circulation, alterations of hepatic and renal functions, the passage of meconium, induction of enzymes, changes in blood oxygen saturation, and recovery of neural tissues (Arnold, Putnam, Barnard, Desmond, & Rudolph, 1965, pp. 77).
Circumcisions are a relatively safe procedure, however, complications can occur and it is important to monitor the infant during and after the procedure. According to Monitor bleeding. Refer to Stanford School of Medicine, while not a complication bleeding post-circumcision of circumcision itself, the application of a tight circular protocol if appropriate bandage may create an obstruction to urine flow and cause urinary retention. Removal of the bandage is Apply petroleum jelly dressing to curative. In most cases, a circumcision site is circumcision adequately dressed when covered with a petroleum jelly coated gauze pad without any taping or circumferential
Resources Arnold, H., Putnam, N., Barnard, B., Desmond, M., & Rudolph A. (1965). Transition to extra-uterine life. The American Journal of Nursing, 65(10), 77-80. Retrieved from http://0-www.jstor.org.libcat.ferris.edu/stable/3419548. Burns E., Schmied V., Fenwick J., & Sheehan A. (2012). Liquid gold from the milk bar: constructions of breastmilk and breastfeeding women in the language and practices of midwives. Social Science & Medicine, 75(10), 1737-1745. Retrieved from www.elsevier.com/locate/socscimed. Stanford School of Medicine. (2013). Complications of circumcision. Retrieved from http://newborns.stanford.edu/CircComplications.html#top.
10
Needs Improvement
(20 points) Assessment has 9-12 blanks (15 points) Chooses inappropriate nursing diagnoses based on the assessment (15 points) Has chosen inappropriate nursing interventions (15 points) Stated inappropriate rationales for nursing interventions (5 points) <10 errors in grammar or spelling; ideas are almost always clearly presented
Meets Expectations
(25 points) Assessment has 5-8 blank spaces, analysis need to be more in depth (17 points) Chooses 1-2 appropriate nursing diagnoses based on the assessment (17 points) Chooses 2-3 appropriate nursing interventions for each diagnosis (17 points) Stated appropriate rationales for nursing interventions for each diagnosis (7 points) <5 errors in grammar or spelling; ideas are clearly presented
Exceptional
(30 points) Assessment has no blank spaces and exceptional analysis (20 points) Chooses 3 appropriate nursing diagnoses based on the assessment (20 points) Chooses 4 or more appropriate nursing interventions for each nursing diagnosis (20 points) In-depth discussion of the nursing interventions for each diagnosis with evidence-based support outside of textbooks (10 points) APA format is excellent; no errors in grammar or spelling; ideas are clearly presented
B. Nursing diagnosis
C. Interventions