17

17
4 34

3
2
3
2
3
17

1
1
4
4 38

3
4

17
APGAR SCORING

SIGNS SCORE TOTAL

0 1 2
ACTIVITY Flaccid Some extremity Active motion 2
flexion
PULSE Absent <100 bpm >100 bpm 2
GRIMACE Floppy Min. response to Prompt response 2
stimulation to stimulation
APPEARANCE Blue/pale Blue extremities, All pink 2
pink body
RESPIRATION Absent Slow and Vigorous cry 2
irregular
TOTAL 10

INTERPRETATION: The newborn baby scored 10 points which is very unusual. The baby appears to be
normal on the APGAR score.
NURSING CARE PLAN

PROBLEM: Pre-mature baby DIAGNOSIS: Late pre-term (36 wks)

PRIORITIZATION: Intensive care and give some resuscitation DATE: October 25, 2022

ASSESSMENT NURSING PLANNING IMPLEMENTATIO RATIONALE EVALUATIO

DIAGNOSI N N
S
Subjective Late pre- in the next 48  Place the  To keep the after 48
term hrs of baby in an baby warm hours of
None gestation monitoring, the monitoring,
incubator and help
of 36 patient should the baby the plan was
weeks. be able to: maintain accomplishe
normal d:
 Identify risk body
factors and temperatur nurse
Objective appropriate e. identified
nursing  Monitor the  Sensors the risk
Preterm birth
interventio vital signs of may be factors and
(36 weeks)
ns the baby taped to appropriate
 Maintain your baby's interventions
Vital signs:
the vital body to and
 Pulse rate
signs monitor maintained
is 160 bpm
blood the vital
 Respiratory
pressure, signs
rate is 45
heart rate,
bpm
breathing
 Temperatu
and
re is 36.7
temperatur
degrees
e.
Celsius

 02
saturation
of 97%