Assessment and Nursing Management and Evaluation – care plan of Normal newborn

Admission Care:

– communication protocol

– History (for both mother and baby)

– Complete physical assessment which include:

– Vital signs.

– Weighing ,length ,head, arm and chest circumferences.

– General appearance.

– Gestational age .

– Prevention of hemorrhage. (Administer Vit. K if not given in delivery room or mother did not have Vit. K before labor).

– identification bands.

– documentation protocol.

Assessment

1. initial assessment (Apgar scoring system).

2.Transitional assessment during the periods of reactivity.

3.Systematic physical examination.

Initial Assessment( Apgar scoring system):

– immediate adjustment to extrauterine life

– heart rate

– respiratory effort

– muscle tone

– reflex irritability

– color

Transitional Assessment during the Periods of Reactivity:

– First period of reactivity ( first -30 min):

Baby ( cries, alert, suck afist greedily)

– Physiologically :

respiratory rate ↑ 80 c / min

crackles may be heard

HR ↑ 180 b/ min

bowel sound is active

↑ mucus secretions

↓ temp slightly

Second stage (2-4 hrs) :

– HR → decrease

– respiratory rates → decrease

– Temp → continues to fall

– mucus production → decrease

–  urine or stool → not passed

– Sleepy and calm

Second period of reactivity( 2-5 hrs):

– alert and responsive

– heart and respiratory rate → increased

– gag reflex is active

– gastric and respiratory secretions → increased

– passage of meconium

Following this stage is a period of stabilization of physiologic systems

Assessment of gestational age:

– refer to high-risk neonate unit

Systematic physical examination:

General Measurements:

– Birth weight: 2700-4000 g.

– Head Circumference: 33-35 cm, about 2-3 cm larger than chest circumference.

– Chest Circumference: 30.5- 33 cm.

– Head to heel length: 48-53cm.

Vital Signs:

– Temperature:

– Axillary: 36.5°C- 37°C.

– Heart Rate:

– Apical 102-140 b/ min.

– Respiratory:

– 30-60 c/ min.

– Blood Pressure:

– 65/41 mmHg.

General Appearance:

Posture ,Skin, Head, Eyes, Ears, Nose, Mouth and throat, Neck

Posture

Flexion of head and extremities while rest on chest and abdomen.

Skin

At birth →bright red, puffy smooh.

Second to third day →dark pink and dry.

soft with good elasticity and tissue turgor

Edema around eye, face, legs and scrotum or labia

Cyanosis of hands and feet

Vernix Caseosa:

– soft yellowish cream, which covers the neonates at birth to protect the skin from infection

– It is formed of sebaceous gland mixed with old epithelial cells.

– It may thickly cover the baby or it my be found only in the body crease and between the labia.

– It dries off within 24-48 hours

Lanugo Hair

– long soft growth of fine hair observed on the shoulders, back, extremities, forehead and temples of the neonate

– The more premature baby is, the heavier the presence of lanugo is

– It disappears during the first weeks of life

Mongolian Spots:

– black coloration on the lower back, buttocks, anterior trunk and rarely on fingers and feet.

They disappear during preschool years without treatment.

image

Desquamation

Pealing of the skin occurs within 2-4 weeks of life

Site : nose, knees and elbows

The skin of buttocks should not be left wet or soiled.

Physiological Jaundice:

– yellowish discoloration of the skin yellowish discoloration

– Appears 2-3 days after delivery

– It is not pathological

– it is associated with excessive destruction of erythrocytes (R.B.C.) that are not needed after birth

– increases for a few days and usually disappears by the 7-10 days.

Milia

These are small pinpoint white or yellow spots due to increased fat secretion

Site :nose, forehead, cheeks, and chin of the newborn infants

consist of accumulations of secretions from the sweat and sebaceous glands that have not yet begun to function normally.

ždisappear within a few weeks and it should not be expressed.

image

Head evaluation

–  The fontanels are soft spots. Consist of openings at the point of union of the skill bones.

– The anterior fontanel; is diamond in shape and located at the junction of two parietal and frontal bones.

– It is 2-3 cm in width and 3-4 cm in length.

– It closes between 12-18 months of age.

– Fontanels should be flat, soft, and firm. It bulge when the baby cries or if there is increased intracranial pressure.

– Two conditions may appear in the head. These are caput succidaneum and cephalhematoma.

Caput Succidaneum; is edema of the scalp resulting from pressure during labor

Cephalhematoma; is a hemorrhage under the periostieum of one of the cranial bones (usually parietal) resulting from trauma of labor.

Eyes Nursing evaluation

– Lids: Usually edematous.

– Color: Gary, dark blue, brown.

True eyes color is not determined until the age of 3-6 months.

– Pupil: React to light.

– Absence of tears.

– Blinking reflex in response to light or touch.

– Rudimentary fixation on objects

Ears Nursing evaluation

– Position: Top of pinna on horizontal line with outer canthus of eye.

– Startle reflex elicited by a loud sudden noise.

– Pinna flexible, cartilage present.

Mouth and throat Nursing Evaluation

– Intact, high-arched palate.

– Uvula in midline.

– Sucking reflex- strong and coordination.

– Rooting reflex.

– Gag reflex.

– Minimal salivation.

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Posted in Maternity, Nursing Care Plans, Nursing Intervention

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