West Visayas State University

COLLEGE OF NURSING

DI
Division of Nursing Fundamentals II
La Paz, Iloilo City

VISION: West Visayas State University as one of the top universities

in Southeast Asia

MISSION: To produce globally competitive students

CASE PRESENTATION

presents

THE MOMENT I SAW YOU CRY

Presented by:
BSN 2C & 2D

Presented to:
Mr. Dexter Cendaa Mrs. Arlyn Salistre
Mrs. Ma. Evelyn Robite Mrs. Jane Daniel
 Prof. Albert Apilado Mrs. Ma. Emida Martinez
Mrs. Joana Janet Gorriceta Mr. Marky Legaspi
Prof. Janet Marie Gequillana Mrs. Ma. Teresa Cercado
General Objectives:

At the end of the case presentation, we will be able to inculcate

the knowledge, skills and attitude specific in the case of our patient and

also to our future patients in order to embody the true essence of being a

WVSU student nurse, thus elevating the nursing competence learned in

our related learning experience

Specific Objectives

After 8 hours of case presentation, the students will be able:

1. To identify deviations from normal neonatal measurements.

2. To recognize the medications prescribed for the patient noting their

therapeutic effects and adverse reactions.

3. To distinguish appropriate nursing care plan that includes the dependent,

independent, and collaborative nursing care.

4. To pinpoint misconceptions on performing physical assessments for neonates.

NEWBORN ASSESSMENT
 VITAL INFORMATION
Name: S, Baby Girl
Sex: Female
Address: Boulevard, Molo, Iloilo City
Date and Time of Delivery: July 28, 2016; 6:47 am Type of Delivery: NSVD
Mothers Name: LS Age: 29
Ordinal Position of the child in the Family: 2nd
Attending Physician: Dr. M

GESTATIONAL AGE ASSESSMENT

Based on Ballards Score (in weeks)

Based on LMP (in weeks) 39 weeks

Preterm ( ) Term ( / ) Post term ( )

APGAR SCORE
PARAMETERS 1minute 5 minutes
Heart Rate (2) (2)
Respiratory Rate (2) (2)
Reflex Irritability (2) (2)
Muscle Tone (2) (2)
Color (1) (2)
SCORE 9 10

ME
AS
UR
EMENTS

a) VITAL SIGNS
Date and Time Taken:
Temperature 37.1c
Heart Rate 128 beats/min
Respiratory Rate 45 breaths/min

b) ANTHROPOMETRIC
 UPON AT PRESENT DATE AND
DELIVERY TIME
HEAD 35cm 34cm July 29, 2016
CIRCUFERENCE 5:10pm
CHEST 33cm 32cm July 29, 2016
CIRCUMFERENC 5:10pm
E
LENGTH 42cm 43cm July 29, 2016
5:10pm
WEIGHT 3150g 2800g July 29, 2016
5:10pm
ABDOMINAL 31cm 35cm July 29, 2016
CIRCUMFERENC 5:10pm
E

PHYSICAL ASSESSMENT:

General Appearance:

Awake, appears active, flexion of head and extremities, dressed appropriately

with pink clothes, mittens, and booties, presence of cord clamp attached to cord
stump

a) HEAD AND FACE:

Head = 34 cm, midline, smooth skull contour, fontanels flat soft and firm,
elongated and molded in shape. Face: symmetric facial features, symmetric nasal
folds, no presence of edema, symmetric facial movements.

b) EYES:

Eyebrows: thin, hair evenly distributed, skin intact, symmetrical; eyelashes:

evenly distributed, curled slightly outward; eyelids: intact, no discharge, slightly
edematous; pupil greyish in color

c) EARS:

Same color as facial skin, symmetrical, aligned with outer canthus of the eye,
soft to touch, cartilage is present, firm, no tenderness noted, pinna recoils back when
folded, no inflammation

d) NOSE:

Uniform in color, patent, symmetric, no tenderness, no lesions; nasal septum

intact and in midline
 e) MOUTH:

Lips pink and smooth, high arched palate, uvula in midline, uniform pink in
color, minimum salivation, absence of natal teeth

f) NECK:

Midline, symmetrical, presence of skin folds, uniform in color; lymph nodes

non-palpable

g) CHEST and BACK:

Thorax:
Barrel chest; chest circumference of 32 cm; unlabored and regular respirations
with few periods of apnea of less than 15 seconds; respiratory rate of 45 breaths
per minute;

Anterior Chest:

Symmetrical expansion

Sternum:
Midline; not bulging nor sunken

Heart
Audible upon auscultation with S 1 and S2 pattern; without murmurs upon
auscultation; heart rate of 128 beats per minute;

Clavicles
Appears straight and feels smooth

Spine:
Straight and flat, without dimpling; responsive to trunk incurvation reflex

h) ABDOMEN:

Protuberant contour; abdominal skin uniform in color; no presence of masses;

abdominal circumference of 35 cm; umbilicus located in the center, no discharges,
redness or any sign of infection noted; symmetric movement during respiration

i)ANOGENITAL (including elimination):

Skin is smooth and intact with no presence of lesions, swellings or

inflammations; anus is open for passage of stool

j)EXTREMITIES:
Upper:
Arms are equally same in size and length; uniform in color; generally flexed; no
presence of extra digits on hands; no lesions or bruises noted
 Lower:
Legs are equal in length; uniform in color; generally flexed; no presence of extra
digits; no lesions or bruises noted

k) SKIN:

Pinkish in color; no lesion or masses noted; warm and dry; has good skin
turgor: less than two seconds; uniform in skin color without desquamation; absence of
vernix caseosa; lanugo noted on back and upper extremities

l) NEUROLOGIC:

REFLEXES ASSESSMENT

Reflexes How to Elicit Expected Actual

Response Evaluation
Rooting Reflex A newborns cheek The newborn will Patient turned her
is brushed or turn her head in head towards
stroked near the that direction. brushed cheek.
corner of the
mouth.
Sucking Reflex Letting the The baby will make Patient made a
mothers breast a sucking motion. sucking movement
touch the newborn when mothers
s lips breast touched the
mouth.
Palmar Grasp Place finger in their Newborn grasp the Patient grasped the
Reflex palm. finger in their palm student nurses
by closing their finger.
fingers on it.
Plantar Grasp Using our finger The toes grasp as Patients toes
Reflex touch the the same manner as grasped Student
newborns foot at the finger nurses finger.
the base of the
toes.
Tonic Neck Let the baby lie If you turn a When the patients
Reflex down and turn his newborns head to head was turned to
head to one side or the opposite side the right, the
the other. he will change the patients left arm
 The arm and leg on extension and extended to the
the side toward contraction of the left.
which the head legs and arms
extend, and the accordingly.
opposite arm and
leg contract.
Moro Reflex Hold a newborn in a Sudden backward When the Student
supine position and head movements, Nurse clapped her
make a loud noise the newborn hands loudly, the
by clapping your abducts and extend patient seemed to
hands. arms and legs, then suddenly abduct
swings the arms and extended her
into an embrace legs.
position and pulls
up the legs against
the abdomen.
Babinski Reflex Stroked an inverted The baby should Patient pulled her
J curved from flex his/her foot or foot away.
the heel upward in pull it away.
the sole of a
newborns foot.
Blink Reflex Shining a light into Sudden movement Patient blinked her
an eye. towards the eye. eyes
Swallowing Feeding the child Normal swallowing When patient is
Reflex through BF. Breast feeding, she
swallows the milk.

V. DISCHARGE PLANS AND INSTRUCTIONS

CORD CARE

Various methods of cord care are practiced to prevent infection because the umbilical
stump is an excellent medium for bacterial growth. We taught the mother one of these
methods which is to clean the base of the stump first with a cotton bud soaked in clean water
in an outward motion so as to avoid contamination. Next is to clean the stump itself with
another cotton bud soaked in clean water. It is suggested to use one cotton bud for each side
of the stump to avoid the spread of microorganisms. Then lastly is to clean the cord clamp
with another cotton bud soaked in water also with one cotton bud at each side to avoid
growth of bacteria. Also, the diaper should be placed below the cord to avoid irritation and
wetting. It is also much better to keep the stump dry (also known as the dry method) to
promote quick drying and separation.

FEEDING/NUTRITION

Human milk is the best option for infant nutrition up to 1 year of age. Breast milk
consists of a number of micronutrients that are bioavailable, meaning these nutrients are
available in quantities and qualities that make them easily digestible by the newborn and
absorbed for energy and growth.

Bottle-feeding is an acceptable method of feeding. However, parents who choose

bottle-feeding also need support and assistance in meeting their infants needs. One of the
purposes of bottle-feeding is to help ensure the emotional component of feeding by holding
the infant close to the body while rocking or cuddling them.

(Hockenberry, M. J., Wilson D.(2007). Wongs Nursing Care of Infants and Children. C&E
Publishing, Inc.: Quezon City, Philipppines, pp290-294)

We demonstrated to the mother the appropriate position in holding the baby while
breastfeeding. We taught her how to cradle (same as football) wherein one hand holds the
body and the other holds the head. In feeding the baby, we informed the mother that
breastfeeding is good until 6 months then she can use other forms of milk which can add
nutrients to the baby as he or she grows.

BATHING

In most hospitals, newborn receive a complete bath to wash away vernix caseosa
within an hour after birth. Thereafter, they are bathed once a day, although the procedure
may be limited to washing only the babys face, diaper area and skin folds. Wear gloves or
perform proper handwashing when handling newborns until the first bath, to avoid exposing
your hands to body secretions. Also, bathing should take place 30 minutes after feeding to
prevent discomfort to the baby during bathing.

In bathing, the room should be warm (about 24C) to prevent chilling. If soap is used,
it should be mild and hypoallergenic. The face should be washed with clear water only to
avoid skin irritation. Pilliteri, pp 713

We taught the mother on how she is going to bathe her baby. The first thing to do is to
prepare the things to be used. Then the temperature of the water must be checked using the
dorsal part of the hand. Then while holding the baby in a football hold (wherein one arm
supports the infants head and back while the free hand is used to do the procedure), wet the
head with water while clipping the ears to avoid water from getting inside. Put a little
amount of shampoo to remove traces of vernix caseosa and blood. Rinse with water and dry
thoroughly and gently with a clean towel to prevent chills. As the baby is placed on the
blanket, use cotton balls soaked in water to wipe the eyes from the inner canthus to outer
canthus to avoid cross contamination. Then use a clean cloth for the face, ears and neck.
Rinse it with water again then wipe the anterior part of the body. After wiping with a wet
cloth dry it up to avoid heat loss due to evaporation. Rinse again then wipe the posterior part
of the body in an S pattern. For the genitals, it should be washed with water moving from the
cleanest to the dirtiest part then dry it up. After washing, put a new diaper and fresh clothes
on the baby.

CLOTHING AND WRAPPING

Until the baby is about six months old, he or she will not have the ability to regulate
his or her body temperature well. This means that infants can easily become too hot or too
cold. It is the mothers responsibility to keep the newborn warm and comfortable. She should
be careful not to overdress the newborn. Overheating can increase the babys risk of SIDS
(Sudden Infant Death Syndrome).

One method is wrapping the baby in a receiving blanket. This method is called
swaddling. Swaddling will keep the baby warm and the snug pressure of the blanket around
the infants body gives him or her a sense of security. It also calms down a fussy baby, and it
may just lull him or her to sleep.

We taught the mother on how to swaddle. First is to spread the receiving blanket out
on a flat surface, with a corner folded over. Next is to place the baby down on his or her back
on top of the blanket, with the babys head at the folded corner. Then, wrap the folded
corner of the blanket over the babys body and tuck it underneath him or her. Then bring the
bottom corner up over the babys feet and wrap the right corner around the infant. It should
not cover the babys head or neck.

DIAPERING

We taught the mother that with each diaper change, the area should be washed with
clear water and dried well, to prevent the ammonia in urine from irritating the infants skin
and causing a diaper rash.

SLEEPING POSITION

We taught the mother to position her baby on the back for sleep because placing
infants in a supine position had been shown to decrease the incidence of the syndrome
although the specific cause of SIDS cannot be explained.

(Pilliteri, A.(2007). Maternal and Child Health Nursing: Care of the Childbearing and
Childrearing Family. C&E Publishing, Inc.: Quezon City, Philippines. pp. 714)

CARE OF THE EYES, EARS, NOSE and MOUTH

We taught the mother some procedures on how to clean the eyes, ears, nose and
mouth which are the following:

EYES: Use cotton swabs dipped in warm water to clean the orbs. Press the swabs using the
palms to drain excess water and with the wet swab, clean the babys eyes moving from the
inner canthus towards the outer canthus. It should be done in a gentle manner, first moving
the swab on the upper eyelid and then on the lower eyelid. Do not press; just use the
fingertips. This will make the grime come out easily.

EARS: Wipe the outer ear with a clean, wet cloth after a bath. Dont clean the thick, brown
wax inside the ear because it protects the ear from external infections. Never use cotton
buds or ear buds to clean the babys ears.

NOSE: Use cotton buds to clean the nose. Dont try to insert a finger into those little nostrils.

MOUTH: Wipe the insides with a clean, soft, wet cloth.

SUNLIGHT EXPOSURE

Sunburn can be a source of first- or second-degree burn. We told the mother that
exposure to direct sunlight should be avoided for the first 6 months. We told her to cover the
infants body, especially the face and head when they are under the heat of the sun.
Sunscreen can also be used on older infants but should be used on small areas of the body and
sparingly in infants under 6 months. Although dark-skinned infants burn less readily, their thin
skin can become sunburned and needs protection.
IMMUNIZATION AND FOLLOW-UP VISIT

Immunization Primary Dose Booster Dose

BCG anytime after birth none

DPT 6 weeks of age 6-12 months apart from last

POLIO 10 weeks of age dose of primary series
Hib 14 weeks of age second booster4-6 years of
age
Measles 9 months of age 15 months of age

MMR 12-15 months of age 4-6 years of age

Varicella
Fig. 1 This table shows the list of immunizations needed to be administered to the child at a
given time to decrease the risk of acquiring diseases.

We encouraged the mother to complete her childs immunizations so as to prevent the

transfer of disease from the mother.

Schedule of Postnatal Visits for Mother and Newborn

First visit (could be a home visit) within 1 week, preferably on day 3

Second visit 7-14 days after birth

Third visit 4-6 weeks after birth

Fig. 2 This table shows the timing of subsequent visits to be followed to promote the health
of the baby and the recovery of the mother.

The mother should be aware when to bring her child for a follow up visit. We told the
mother that it is most suggested to monitor the babys development every month. We also
said that it is an important opportunity to ensure the establishment of breastfeeding and
address any difficulties with attachment and positioning.

THERMOREGULATION

Heat regulation is most critical to the newborns survival. Although the newborns
capacity for heat production is adequate, several factors predispose the newborn to excessive
heat loss. First, the newborns large surface area relative to his or her weight facilitates heat
loss to the environment. The second factor is the newborns thin layer of subcutaneous fat.
Since core body temperature is approximately 1F higher than surface body temperature, this
temperature difference causes a heat transfer from a higher to lower temperature. A third
factor is the newborns mechanism for producing heat. Unlike the child or adult, who can
increase heat production through shivering, the chilled neonate cannot shiver but produces
heat through nonshivering, or chemical thermogenesis. Because of these factors predisposing
infants to loss of body heat, it is essential that newly born infants are quickly dried and either
provided with warm, dry blankets or placed skin-to-skin with their mothers after delivery.
(Wongs, pp 258-259)

We told the mother to monitor the axillary temperature of the baby frequently for
thermoregulation. We also told her to provide warmth by swaddling and by establishing skin-
to-skin contact. It is also important to avoid situations that predispose the infant to heat loss
such as cool air, bathing and cold bedding.

NEWBORN SCREENING

A large number of congenital disorders can be detected in the newborn period by

blood sampling so that early intervention can take place to decrease the long-term effects
and cost of not treating such conditions. All states now mandate screening tests for
phenylketonuria (PKU) and congenital hypothyroidism.

We asked the mother if the baby had undergone newborn screening and she
immediately said yes. We told her that it is a good thing that her baby had been screened so
that the health professionals can treat certain conditions that are identified at birth and
prevent it from spreading.

BREAST CARE

We gave the mother some tips on how to care for her breasts. First is to wash the
breasts with water daily for cleanliness. Second is to air dry the nipples after each feeding.
Third is to apply a few drops of breast milk after a feeding and let air dry if nipples are sore
and to apply warm packs and express milk if breasts are engorged.

BELIEFS and FALLACIES REGARDING CHILD CARE

Newborn babies are also kept very warm and are protected from anything that might
startle or frighten them. The mothers first milk, colostrum, is considered dirty in Filipino
culture, so relatives feed the baby sugar water or formula for a few days until the mothers
regular milk comes in. Some women also believe that their emotions can be transmitted
through breastmilk and may avoid feeding their babies when they are upset or angry. These
beliefs, combined with communal baby care practices and formula marketing in the
Philippines, can sometimes lead to problems with breastfeeding.

We told the mother not to believe in any beliefs and fallacies regarding child care and
encouraged her to follow our advice and health teachings and also the doctors orders to
ensure good postnatal care and to provide a safe and adequate home environment for the
baby.

TEXTBOOK DISCUSSION
Definition of Terms

Newborn

Newborns undergo profound physiologic changes at the moment of birth as they

released from a warm, snug, dark, liquid-filled environment that has meet all
of their basic needs into a chilly, unbounded, brightly lit, gravity-based, outside
world. Within minutes after being plunged into this strange environment, a
newborn has to initiate respirations and adapt circulatory system to
extrauterine oxygenation. Within 24 hours, neurologic, renal, endocrine,
gastrointestinal and metabolic functions must be operating competently for life
to be sustained. How well a newborn makes these major adjustments depends
 on his or her genetic composition, the competency of the recent intrauterine
environment, the care received during the labor and birth and the care
received during the newborn or neonatal period (the time from birth through
the first 28days of life) ( Walsh & Goser, 2013). One half of all deaths that
occur during the first years of life occur in the neonatal period. More than half
occur in the first 24 hours after birth an indication of how hazardous a time
this is for an infant (World Health Organization, 2012)

Vital Statistics

measured for a newborn usually consist of the babys weight, length, and head
chest circumference.

Head Circumference 34-35 cm

Temperature - 35.5-36.5 C per axilla

Chest Circumference 32-33 cm

Heart Rate 120-160 bpm

Respirations 30-60 breaths/min

Weight 3.4 kg or 7.4 lb (normal mature female):

3.6 kg or 7.9 lb (normal mature male)

Length 49 cm or 19.2 inc (normal mature female):

50 cm or 19.6 inc (normal mature male)

Central Cyanosis

the cyanosis of the trunk is always a cause of concern. It indicates decrease

oxygenation that could be occurring as the result of a temporary respiratory
obstruction and also could reflect a serious underlying respiratory or cardiac
disease

Physiologic Jaundice
when skin and sclera of the eyes begin to appear noticeably yellow on the
second or third day of life as a result of breakdown of fetal red blood cells
Cephalohematoma

collection of blod under the periosteum of the skull bone caused by pressure at
birth

Harlequin Sign
because of immature blood circulation, a newborn who has been lying on his
side appears red on the dependent side of the body and pale on the upper side,
as if a line had been drawn down the center of the body.

Mongolian Spots

are collections of pigment cells (melanocytes) that appear as slate gray

patches across the sacrum or buttocks and possibly on the arms and legs of the
newborn.
Epstein Pearls
 are one or two small round, glistering, well circumscribed cysts that can be
seen on the palate from the extra calcium having been deposited in the utero
Vernix Caseosa

is the white, cream cheese-like substance that serves as a skin lubricant in

utero.

Lanugo
is a fine, downy hair that covers a term newborns shoulders, back, upper
arms, and possibly also the forehead and ears.
Desquamation

when within 24 hours of birth, the skin of most newborns begins to dry.
Milia

sebaceous glands in a newborn or immature, so at least one pinpoint white

papule is usually found on a cheek or across the bridge of the nose of the
newborn.
Erythema toxicum

newborn rash
Forceps marks

they are left circular or linear contusion matching the rim of the forceps
blade on the infants cheek.

Fontanelles
are spaces or openings where the skull, bones join.

Anterior Fontanelle
located at the junction of two parietal bones and two fused frontal bones.
Diamond in shape and measures 2-3cm in width and 3-4cm in length and
closes at 18 months.

Posterior Fontanelle
located at the junction f the parietal bones and the occipital bone.
Triangular in shape, measures 1-2cm in length and closes between2-3months.
Caput succedaneum

edema of the scalp that forms on the presenting part of the head.
Meconium

a collection of cellular wastes, bile, fats, mucoproteins and portions of the

vernix caseosa, accumulates at the first 16weeks. This is the first stool of
the newborn which is sticky in consistency and appears black or dark green.

Central Cyanosis (-)

Physiologic Jaundice (-)
Cephalohematoma (-)
Harlequin Sign (-)
Mongolian spots (+) buttocks, arms and legs
Vernix Caseosa (+) Skin folds
Lanugo (+) shoulders, back, upper arms, forehead
 and ears
Desquamation (+) palms of hand and soles of feet
Milia (+) cheek, across bridge of the nose
Erythema toxicum (-)
Forcep Marks (-)
Caput succedaneum (-)
Nursing Management done by student nurse on the
client

Monitored weight

Observed infants color and respiratory pattern

Monitored Vital Signs; observed for signs of temperature instability such as respiratory
distress

Observed for any evidence of infection especially at the umbilicus; checked

identification bands;

verified administration of prophylactic eye treatment, vitamin K injection and heap B

vaccine.

Observed interactions between infant and family members

Observed parents ability to provide care for infant

Medical Management/Intervention done to the client

Vitamin K on right anterolateral thigh

Hepa B vaccine 0.5 mL on left anterolateral thigh

BCG 0.05 mL Intradermal

Treatment or Procedures

Terramycin eye ointment on both eyes

LIST OF NURSING DIAGNOSIS IDENTIFIED

1. Risk for falls related to unattended newborn in bed
2. Risk for infection related to inadequate acquired immunity
3. Ineffective thermoregulation
4. Risk for Hypothermia
5. Risk for suffocation

a.) FDAR
 NURSING PROGRESS NOTES

Date/Ti Focus Data Action Date/Ti Response

me me
July 28, Risk for - Lack of - Provided July 28, Mother of
2016 falls pillows a chair 2016 the
4:00 related surroundi at the 8:00 newborn
p.m to ng the side of p.m verbalized
unatte infant the bed understan
nded - Absence for ding of
newbor of side safety safety
n in rails on purposes precaution
bed bed in case s such as
- Unattend the baby leaving
ed falls off the baby
newborn the bed alone can
in bed - Instructe contribute
d the to the
mother possibility
to put of falls.
pillows
beside Pillows
the baby placed
- Instructe around the
d the baby.
mother
not to
leave
the
newborn
unattend
ed
- Gave the
clients
mother
teaching
s about
safety
precauti
ons
b.) SOAPIE

July 28, 2016

4:00 PM

S (subjective cues)
- No subjective cues

O (Objective cues)
- Lack of parental supervision
- Absence of side rails on bed
A(Action)/P (Planning)
- Risk for falls related to unattended newborn in bed

I (Intervention)
- Provided a chair at the side of the bed for safety purposes in case the baby
falls off the bed
- Instructed the mother to put pillows beside the baby
- Instructed the mother to not leave the newborn unattended
- Gave the clients mother teachings about safety precautions

July 28, 2016

8:00 PM

E (Evaluation)
- Mother of the newborn verbalized understanding of safety precautions such as
leaving the baby alone can contribute to the possibility of falls.

- Pillows placed beside the baby.