CANCINO, ANGELA ANN M.

BSN II-A
Mrs. Anita is 40 years of age and gave birth to her third baby at Blessed Family Doctors Hospital
5 days ago. Her labor, and birth were uncomplicated but she experienced gestational diabetes and
hypertension during pregnancy. Mrs. Anita noticed yesterday that her baby’s cord stump had an
offensive smell. She has brought Baby John to the health center for the first time today because
she is concerned that the cord may be infected.  Also concerned if she still has diabetes and
hypertension.

PRE-ASSESSMENT
1. Before beginning your assessment, what should you do for and ask Mrs. Anita and
Baby John?
First and foremost, greet the patient and collect demographic information such as the baby's
name and date of birth. By correctly identifying the patient, the nurse will be able to learn about
the newborn's full medical condition and history, which will aid in providing the necessary
treatment. This can also help to reduce the negative consequences of avoidable patient
identification errors. Then, ask her what is her problem, is her pregnancy, labor, and birth
uncomplicated? Is her baby feeling well? Finally, inform her that you will conduct a physical
examination on his baby to determine the cause of the problem.

2. What history will you include in your assessment of the mother and Baby John and
why?
The history that will be included in my assessment of the mother and Baby John is the birth
weight, which is an important indicator of the newborn's health; vital signs include the mother's
blood pressure and the baby's temperature, pulse rate, and respiratory rate; the physical
examination is an important part of newborn care to carefully check each body system for health
and normal function, which includes general appearance, skin color, the abdomen, and the cord
stump. Aside from the above history, I should include the following in the assessment: is there
any bleeding in the umbilical cord, has the baby vomited, and is the baby crying all the time?
Because if we assess the above assessment, we can find out the baby’s present condition and can
evaluate the baby's problem.

3. What physical examination will you include in your assessment of the mother and baby
John and why?
The physical examination I will include in my assessment is the cephalocaudal, which is from
head to toe and includes general appearance, if awake, crying, or irritated (notice the newborn's
facial expressions), skin, neck, face, mouth, lungs, heart sounds, and pulses in the groin
(femoral), abdomen, genitals, and anus, arms, and legs. Examine the newborn's vital signs,
including heart rate, respiratory rate, and temperature, as well as those of the mother and her
blood pressure. Before using a stethoscope to check for the newborn's VS, make sure the
instrument is warm. Examine the skin around the cord stump for signs of redness and swelling.
The appearance and odor of the cord stump – examine the cord for redness and swelling, as well
as any foul odors or odors coming from it. The appearance and smell of the discharge from the
cord stump - note the color of the discharge coming out and the smell of it. This physical
examination allows me to determine the mother's and baby's physical conditions.

4. What laboratory tests will you think the doctor will include in the assessment of the
mother and baby John and why?
I think the laboratory test that the doctor will include in the assessment of the mother and baby
john is the blood test: cord blood testing to find out the blood level and is usually done if there is
a suspected infection in the umbilical cord, blood culture for aerobic and anaerobic organisms to
detect the infection, and bilirubin to detect the bilirubin level in the blood. The fasting blood
sugar test is for mother to find out if her blood sugar levels are in a healthy range.

History:
o  Baby weighed 3 kg at birth
o  Mrs. Anita reports that she had no infection during pregnancy, labor, or birth.
o  Mrs. Anita had FBS 140mg/dl and BP of 150/90 during pregnancy
o  The birth was attended by a doctor in a private hospital
o  Baby John is reportedly not breastfeeding well.
o  Mrs. Anita denies covering cord or putting any substance on the cord.

Physical Examination:
o  Baby E weighs 3 kg.
o  Vital signs are as follows: Respirations are 40 per minute, Temperature is 37.9°C. Baby John
has a moist cord stump that has an offensive smell and redness on surrounding area.
o  None of the following are observed: draining pus, skin lesions, or distended abdomen.
o  You observe that Baby John is having difficulty in breastfeeding
o  Mrs. Anita’s BP is 110/70mmhg

 5. Based on your assessment and diagnosis what would be your nursing care plan for the mother
and the baby.  One NCP for the mother and one for the baby.
 LYCEUM-NORTHWESTERN UNIVERSITY
COLLEGE OF NURSING

Related Learning Experience

Assessment Planning Implementation Rationale Evaluation

Problem: Short-term Goal: Independent STG:
Nursing
Mrs. Anita noticed Within 5-10 minutes Intervention: After 5-10 minutes of
yesterday that her of nursing nursing intervention
baby’s cord stump intervention the infant Monitor vital signs To keep track of the infant were able to
had an offensive will have his cord baseline data. have his cord clean.
smell. She has clean.
brought Baby John Perform Infant To cleanse the body
to the health center Long-term Goal: Sponge Bath of microorganisms
for the first time this would provide LTG:
Within 3 days of
today because she comfort to the baby At the end of our care
nursing intervention,
is concerned that and may help cool a all goals were met as
the cord may be the infant will remain fever. evidenced by:
infected. free of infection as
evidenced by: Perform Cord Care, To promote healing  Cord stump
Subjective: fold diapers down of the cord stump appeared dry and is
The umbilical cord is healing well, no
healing and free of to expose the cord and prevent
“ I noticed that my infection infection. Keeping surrounding
baby’s cord stump the cord exposed redness
 Cord stump is  Absence of foul
has an offensive facilitates drying
dry and no odor
smell, the cord may and inhibits bacterial
surrounding
be infected” as growth.  Vital signs within
redness
verbalized by the normal range
 Absence of foul T = 36.5 – 37.2
patient’s mother. Clean the cord with To reduce the
odor
betadine solution microorganism that °C
 Vital signs will cause infection.
Objective:
remain within R = 30 – 60
-Baby E weighs 3
normal range Early detection of bpm
kg Observe neonate
T = 36.5 – 37.2 signs of infection
-has a moist cord for signs and
°C can provide prompt
stump with an symptoms of
offensive smell. R = 30 – 60 infection. Assess intervention.
-Redness around bpm cord for erythema,
cord stump bleeding, foul odor
-having difficulty and purulent
in breastfeeding discharge
V/S taken as
follows:
Temp: 37.9°C
RR: 40 bpm Dependent Nursing
Intervention:
Nursing Diagnosis:
Risk for Infection Administer IV To fight the
as evidenced by a antibiotics as infection.
moist cord stump prescribed by the
with an offensive doctor.
smell, redness
around the cord
stump, and a body
Collaborative
temperature above
Management:
the normal range.
Obtain blood To identify if there’s
culture for cord a suspected infection
blood testing and in the umbilical
send for lab test. cord.

LYCEUM-NORTHWESTERN UNIVERSITY
COLLEGE OF NURSING

Related Learning Experience

Assessment Planning Implementation Rationale Evaluation

Problem: Short-term Goal: Independent STG:
Nursing
Mrs. Anita noticed After one hour of Intervention: After one hour of
yesterday that her intervention, the intervention, the
baby’s cord stump mother will learn how Instruct mother to In order to prevent mother was able to
had an offensive to give proper cord wash hands before infection. learn how to give
smell. She has care by giving the cleaning and proper cord care by
brought Baby John proper and hygienic checking the cord. giving the proper and
to the health center method of cleaning hygienic method of
for the first time the remaining Inform the In order to the cleaning the
today because she umbilical cord. mother to never try mother to have remaining umbilical
is concerned that to remove the cord; knowledge about the cord.
the cord may be Long-term Goal: let it dry and fall normal umbilical
infected. off cord and it will fall
After one day of by itself. off on its own LTG:
 usually within 1-3
Subjective: nursing intervention, weeks. After one day of
the mother will be Tell the mother to nursing intervention,
“I noticed that my able to give proper refrain from It keep the tummy the mother was able to
baby’s cord stump cord care to the baby. bathing the baby, clean as well as dry give proper cord care
has an offensive until the infection and may help cool a to the baby.
smell, the cord may gets cleared. fever.
be infected” as Instead, sponge
verbalized by the baths can be given
patient’s mother. to the baby.

Objective: Instruct mother on

-has a moist cord how to clean the To reduce the
stump with an cord with betadine microorganism that
offensive smell. solution or warm will cause infection.
-Redness around water.
cord stump
-having difficulty When putting a
in breastfeeding diaper on, ensure In order to keep that
-need information that the belly region area dry.
on how to do is not covered.
proper cord care
V/S of infants Never use alcohol
taken as follows: or any such liquids To prevent any
Temp: 37.9°C on the cord without complications and
RR: 40 bpm medical supervision infection.

Nursing Diagnosis:
Risk for Infection Dependent Nursing
as evidenced by Intervention:
Give antibiotic
inadequate proper
ointment as Use the antibiotic
cord care. ointment only if you
prescribed by the
doctor. see more pus

Collaborative
Management:
Encourage the
mother to seek help Seeking help from
on how to other health team
breastfeed the members will
infant. provide knowledge
on how to do it.
Breastfeeding will
provide the newborn
with antibodies
against infections.