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    SPB Newborn Careplan 1

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    This document provides a care plan for a normal newborn baby girl born to Dhanalaksmi via normal vaginal delivery. It includes biographical information about the mother and baby, details of the delivery and newborn assessments, physical examination findings of the baby, reflex assessments, nursing diagnoses of risk for hypothermia, ineffective breastfeeding, risk for infection, and risk for trauma, and nursing care plans to address each diagnosis. The care plans include objectives, interventions, implementation, and evaluations.

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    SPB Newborn Careplan 1

    Uploaded by

    S G
    119 views12 pages
    This document provides a care plan for a normal newborn baby girl born to Dhanalaksmi via normal vaginal delivery. It includes biographical information about the mother and baby, details of the delivery and newborn assessments, physical examination findings of the baby, reflex assessments, nursing diagnoses of risk for hypothermia, ineffective breastfeeding, risk for infection, and risk for trauma, and nursing care plans to address each diagnosis. The care plans include objectives, interventions, implementation, and evaluations.

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    This document provides a care plan for a normal newborn baby girl born to Dhanalaksmi via normal vaginal delivery. It includes biographical information about the mother and baby, details of the delivery and newborn assessments, physical examination findings of the baby, reflex assessments, nursing diagnoses of risk for hypothermia, ineffective breastfeeding, risk for infection, and risk for trauma, and nursing care plans to address each diagnosis. The care plans include objectives, interventions, implementation, and evaluations.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    119 views12 pages

    SPB Newborn Careplan 1

    Uploaded by

    S G
    This document provides a care plan for a normal newborn baby girl born to Dhanalaksmi via normal vaginal delivery. It includes biographical information about the mother and baby, details of the delivery and newborn assessments, physical examination findings of the baby, reflex assessments, nursing diagnoses of risk for hypothermia, ineffective breastfeeding, risk for infection, and risk for trauma, and nursing care plans to address each diagnosis. The care plans include objectives, interventions, implementation, and evaluations.

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    of 12

    THE OXFORD COLLEGE OF

    NURSING
    Begur road, Hongasandra, Bangalore

    CHILD HEALTH NURSING

    Care plan on:


    Normal Newborn

    SUBMITTED TO
    Ms. Marilakshmi
    Lecturer in Pediatric Nursing
    The Oxford College of Nursing
    Bangalore

    SUBMITTED BY
    Soumya Jose
    I Yr M.Sc. Nursing
    The Oxford College of Nursing
    Bangalore

    SUBMITTED ON: 18-03-2010


    Normal newborn

    INTRODUCTION
    As a part of our clinical experience in Pediatric nursing, we were posted to PHC at
    Chandapura, Bangalore. When I was posted to labour ward, I came across the patient by name
    B/O Dhanalaksmi. full term normal vaginal delivery. I have selected this case for my care plan
    on 04/03/10 in order to use this knowledge in my day to day clinical practice.

    I. BIOGRAPHICAL INFORMATION

    Name : B/O Dhanalaksmi.

    Age : 1 day

    Sex : Female

    Address : D/o Nagaraj

    #26, 2nd cross,

    Anekal mainroad,

    Chandapura

    Bangalore

    Karnataka

    Religion : Hindu

    Date of birth : 04/03/2010

    Type of labour : Full term normal vaginal delivery

    APGAR score : 9/10

    II. MOTHER’S OBSTETRICAL HISTORY:


    ANTENATAL HISTORY
    Mrs. Dhanalaksmi.had regular antenatal checkup. She had received 2 doses of
    inj. T.T. had has taken iron and folic acid supplements throughout her pregnancy.
    INTRANATAL HISTORY
    Time of delivery : 04/03/2010 at 10:30 am
    Membranes ruptured : Spontaneously
    Character of amniotic fluid : Clear
    Placenta and membranes : Normal

    III. HISTORY OF BABY:


    Date and time of birth : 04/03/2010 at 10:30 am
    Condition at birth : Active

    APGAR score:-
    Parameter 1 min 5 min
    Color 2 2
    Respiratory effort 2 2
    Heart beat 2 2
    Muscle tone 1 2
    Responses 2 2
    Total 9 10

    TREATMENT AT BIRTH
    Airway cleared by suctioning. Eye care given. Vernix cleaned. Cord
    clamped and cut short. Weight checked. Shown the baby to mother and relatives.
    Kept the baby under warmer.

    FEEDING
    Breast feeding initiated within ½ an hr i.e.11:00 am

    IMMUNIZATION : BCG, OPV, HBV given


    PHYSICAL EXAMINATION

    GENERAL EXAMINATION:

    Weight : 2.8 kg

    Length : 50cm

    Head circumference : 33cm

    Chest circumference : 32 cm

    Head : Head size in proportion to the body

    Fine distribution of hair, no injury on the scalp, no caput;


    anterior fontanelle diamond shaped and normal

    Posterior fontanelle triangle shaped and normal

    Eyes : symmetrical; no discharge

    Nose : patent no nasal flaring

    Ears : symmetrical, no discharge

    Skin : pinkish, no birth marks

    Mouth : normal, no congenital anamolis

    Heart : S1, S2 heard- no murmur HR- 140beats/ min

    Lungs : symmetrical chest expansion RR 38 breaths/min

    Abdomen : soft, no distension, no hepatomegaly

    Limbs : moves well, normal

    Genitalia : normal, no deviation; labia minora covered with labia


    majora.

    Feeding pattern : demand feeding, exclusive breast feeding

    Activity : active, good cry

    Sleep : sleeps 16-18 hrs

    Hygiene : not maintained well by the mother


    Elimination pattern : meuconium eliminated after 4hrs of birth and voided after
    ½ an hour of birth.

    REFLEXES
    Reflexes Elicited Not elicited
    Eyes
    Glabellar reflex 
    Corneal reflex 
    Papillary reflex 
    Doll’s eye reflex 

    Mouth and throat


    Sneezing reflex 
    Rooting reflex 
    Sucking and swallowing 
    Gag reflex 
    Extrution reflex 
    Yawing reflex 
    Coughing reflex 

    Extremities
    Palmar grasping 
    Plantar grasping 

    Other reflexes
    Tonic reflex 
    Babinski reflex 
    Moro reflex 
    Startle reflex 
    Traction reflex 
    Parachute reflex 
    Stepping reflex 
    Dancing reflex 
    Perez reflex 
    INVESTIGATIONS : nil

    NURSING DIAGNOSIS
    1. Risk for hypothermia related to immaturity of thermoregulatory center

    2. Ineffective breast feeding related to maternal discomfort

    3. Risk for infection related to immature immune system

    4. Risk for trauma related to physical helplessness, and improper practices by the
    mother
    NURSING CARE PLAN
    PLANNING
    ASSESSMENT DIAGNOSIS IMPLEMENTATION EVALUATION
    OBJECTIVE INTERVENTIONS

    Objective data- Risk for Baby will be Assess the baby’s body Assessed the baby’s Baby’s risk for

    mother is not hypothermia free from the temperature temperature which is 98.4F hyperthermia is

    mummifying related to risk of Avoid unnecessary Avoided unnecessary reduced. The

    the baby immature developing exposure to cool area exposure. mother verbalizes

    properly. thermoregulatory hypothermia Establish rooming in of Rooming in and bonding the understanding

    center. the mother and the baby established of mummifying,

    Mummify the baby Mummified the baby rooming in,

    Teach the mother to Taught the mother to bonding and

    mummify mummify keeping the baby

    Encourage the mother to Instructed the mother to dry.

    change the baby’s wet change the baby’s wet cloth

    cloth immediately immediately

    Avoid baby’s contact Avoided baby’s contact with

    with cool objects cool objects


    PLANNING
    ASSESSMENT DIAGNOSIS IMPLEMENTATION EVALUATION
    OBJECTIVE INTERVENTIONS
    Objective data:- risk for infection Baby will be Assess the general Assessed the general condition The mother
    mother is not related immature free from condition of the baby of the baby which looked verbalizes the
    maintaining the immune system infection normal understanding of
    hygiene of the Observe strict hand Strict hand washing observed importance of hand
    baby. washing and also explained to mother. washing ,
    Monitor the vital signs Checked the vitals of the baby exclusive breast
    Temp-98.4F, HR- 120/min, feeding and
    RR- 36/min. demand feeding
    Checked the skin for rashes,
    Check the baby’s skin for redness, and peeling. No such Chances of
    rashes, redness, peeling findings infection reduced.
    Advise the mother Advice given regarding
    regarding exclusive breast exclusive and demand breast
    feeding and demand feeding to increase the
    feeding immunity.
    Provide eye care and cord Eye care and cord care
    care to the baby provided
    Restrict the visitors One visitor at a time allowed.
    PLANNING
    ASSESSMENT DIAGNOSIS IMPLEMENTATION EVALUATION
    OBJECTIVE INTERVENTIONS
    Objective data: Ineffective Assess the mothers Assessed the mother’s breast
    mother is not breast feeding Normal breast breastfeeding methods feeding methods which is not Mother is able to
    feeding the baby due to maternal feeding paterns correct. fulfill the baby’s
    in correct discomfort will be Provide extra pillows to Provided extra pillows to the feeding demand by
    position . maintained the mother mother to provide correct assuming correct
    position of breast feeding. position and using
    Teach the importance Taught the importance and correct technique
    and technique of breast correct technique of breast of breast feeding.
    feeding and assist in feeding and assisted in breast The mother
    feeding feeding verbalizes the
    Advice the mother to Advised and demonstrated understanding of
    burp the baby after each the mother to burp after each breast care and
    feed feed personal hygiene.
    Teach regarding breast Taught regarding breast care
    care
    Advice her to maintain Advised regarding personal
    personal hygiene hygiene
    PLANNING
    ASSESSMENT DIAGNOSIS IMPLEMENTATION EVALUATION
    OBJECTIVE INTERVENTIONS
    Objective data: Risk for trauma Risk for Advice the mother never Advised the mother to Risk for truma will
    baby was kept related to trauma will be leave the baby unattended always be with the baby be reduced as the
    near the edge of physical reduced or Advice to keep the baby Advised to keep the baby mother verbalizes
    the cot and was helplessness Baby’s body away from the edge and away from the edge the understanding
    left unattended and improper temperature towards the mother of methods to
    practices by the will be Teach proper handeling Taught proper handling and prevent accident
    mother maintained to and positioning of the positioning of the baby to
    normal baby prevent accidents
    Advice to keep the nails Advised to keep the nails
    short short
    Advice to keep the baby Advised to keep the sharp
    away from the sharp thing at a distance
    things
    Encourage the family Encouraged the family
    members to participate in members to participate in
    baby care baby care
    BIBLIOGRAPHY

    1. Suraj Gupte .A short text book of Pediatrics.11th ed. Jaypee publications;2009.

    2. Hockenberry MJ. Wong’s essentials of Pediatric nursing.7th ed. Mosby publications;2007.

    3. Marlow DR, Redding AB.Text book of Pediatric nursing. 6th ed. Philadelphia: Elsevier publications;2006

    4. Agarwal RK etal.IAP Text book of pediatrics. 4th ed. Jaypee publications;2009

    5. Chellappa J. M. Pediatric nursing. 1st ed. Gajanana publishers:Bangalore; 1995

    6. Ghai OP, Paul VK, Bagga A. Essential pediatrics. 7th ed. CBS publishers : New Delhi; 2009.

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