CHILD HEALTH NURSING

CASE SCENARIO

Programme : III Year BSCN

Condition : Normal Neonate

B/O Anita, a term male boy baby was born before 5 minutes via normal vaginal delivery.
Birth weight is 3.530gms. He is being taken care by a nurse in the baby care area.

On Examination:

 Baby is pink, active and alert

 APGAR score is 7 and 10 at 1st and 5th minute
 Temp is 98◦F
 HR is 142/mt
 RR is 44/mt
 On auscultation: minimal crackles and stridor present
 Good suckling movements present
 Meconium and urine passed
 Anus is patent
 No abnormalities or congenital anomalies present

Management and Teaching points:

1. Maintain thermoregulation
2. Promote clear airway and oxygenation
3. Promote fluid status
4. Prevent infection
5. Prevent injury and bleeding
6. Promote bonding
Requirements:
 Kardex
 Nurses Notes
 Medicine cards if administered
 Investigation chart
 Feeding chart
 Nursing process according to NANDA: Wellness and illness diagnosis
 Immunization schedule
 Growth and Development:
 Reflexes
 Head to foot examination
 Theories of development
 Play therapy and play materials
Health Education:
 Newborn care
 Importance of breast feeding
 Prevention of infection
 Prevention of injuries
 Immunization
KARDEX

Da Medic D R Fre Ti Nursing diagnosis and

te ation o o q m interventions
s ut e
e e
Inj. 1 I Stat At1. Risk for ineffective airway clearance
Vit K M bi related to mucus and secretions
m rt
2. Ineffective thermoregulation related
g Stat h
to immature heat-regulating
Inj. I
mechanisms
Hep B M At
0 Stat bi 3. Risk for injury: hypoglycemia related
. rt to immature metabolism and/or
OPV 5 O h presence of risk factors
ra
m l At4. Risk for infection related to
g immature immune system, possible
bi
exposure to pathogens in the birth
rt
canal or in the nursery, umbilical
2 h
cord wound, cross contamination.
d
r 5. Risk for imbalanced fluid volume
o related to immature blood clotting
p mechanisms.
s
6. Risk for injury: misidentification
related to failure of delivery room
personnel to adequately identify the
newborn before separation from the
parents.
7. Risk for impaired skin integrity
8. Risk for disorganized infant behavior
related to pain, invasive procedures,
or environmental over stimulation

9. Effective sucking related to good

sucking reflex in the baby and
normal milk production in the
mother
10. Deficient knowledge (parental)
related to normal newborn care
 Assess the general condition of the
baby.
 Assess the APGAR score at 1st and
5th minute.
 Wipe and dry the baby immediately
after birth.
 Perform physical examination
immediately after birth.
 Ensure that adequate supplies are
present for a full resuscitation and
that all equipment is functioning
properly.
 Have a newborn resuscitation board
that is stocked with needed supplies.
 Check that oxygen is readily
available and that there is a
functioning suction source.
 Ensure that a warmer is in the
delivery area, and turn it on several
minutes before the delivery is
expected.
 Observe the newborn carefully at
birth.
 Suction the mouth and nose with a
bulb syringe and clamp and cut the
umbilical cord.
 If the newborn cries vigorously drape
a blanket over the mother’s abdomen
and support the infant.
 Monitor the HR
 A pulse above 100 bpm and a
vigorous cry are reassuring signs that
indicate the newborn is making a
successful transition.
 If the newborn does not cry
immediately, he must be transported
to a preheated radiant warmer for
prompt resuscitation.
 Dry quickly to prevent heat loss from
evaporation and to provide
stimulation to encourage a first
breath.
 If the baby doesn’t have adequate
breathing efforts, a bag and mask
connected to 100% oxygen are used
to provide respiratory support until
spontaneous breathing occurs.
 A short period of positive-pressure
ventilation with a bag and mask is
used for the neonates if not breathing
well.
 Perform chest compressions,
intubation, and medications if
necessary.
 Give constant attention to the airway.
Newborns often have abundant
secretions.
 Position the newborn on the side or
with the head in a slightly lower
position than the body to help
prevent aspiration of secretions.
 A bulb syringe is used to suction the
mouth first and then the nose
 Keep the bulb syringe with the
newborn and teach the parents how
and when to suction the baby.
 If copious secretions are present that
do not resolve with a bulb syringe, a
small suction catheter connected to a
suction source may be used.
 Do not apply suction for longer than
5 seconds at a time and to minimize
suction pressures to avoid damaging
the delicate respiratory structures.
 Position the newborn on the side or
back to sleep.
 Quickly dry the newborn on the
mother’s abdomen, swaddle him
snugly, and apply a cap to prevent
heat loss.
 Maintain the newborn’s temperature
and promote early bonding.
 Place a diaper or blanket over the
genital area and a cap on the head,
then place the newborn skin-to-skin
with the mother or father and cover
them both with blankets called as
kangaroo care.
 It is important to support
thermoregulation in the newborn,
particularly in the first 24 hours of
life.
 The environmental temperature
necessary to maintain a
thermoneutral environment is slightly
higher for the newborn than that
required for an older child or adult.
 Take care to prevent unnecessary
heat loss in the nursery as drafts of
air can cause convective heat loss,
and placing a newborn on a cold
surface can lead to conductive heat
loss.
 Conversely, do not allow the
newborn to become overheated as
hyperthermia can be just as harmful
as hypothermia.
 A skin temperature probe should be
in place on the skin anytime the
newborn is under the radiant warmer,
and alarms should be set to signal if
the skin temperature becomes too
hot.
 Follow universal precautions. Do not
handle the neonate without gloves
until after the bath.
 Careful hand washing and strict
aseptic technique should be used
when caring for the cord.
 keeping all of the newborn’s
belongings together in the bassinet
and not sharing items between
newborns.
 Equipment that is used on multiple
newborns, such as a stethoscope, is
usually wiped down with alcohol
between uses.
 Rooming-in also reduces the
likelihood of cross-contamination.
 Keep the infant wrapped and expose
only the body part being washed
during bath.
 Use a mild shampoo on the head.
 Encourage the parents to participate
in the bath to interact with their baby
and help them gain confidence in
parenting skills.
 When the bath is finished, check the
axillary temperature. If it is within
the expected range, dress the
newborn in a shirt, diaper, and cap.
 Swaddle the newborn in a blanket
and place him in an open crib. If the
temperature is below 36.4C (97.5F),
return the newborn to the radiant
warmer.

 Change diapers frequently to prevent

diaper rash and skin breakdown.
 Do not apply special oils or
ointments on clean, intact skin.
 Do not apply talc powders as they
can cause respiratory irritation when
particles are inhaled.
 Fold the diaper down in the front so
that the cord is left open to air.
 Use antiseptic solution such as triple
dye, bacitracin ointment, or
povidone-iodine initially to paint the
cord to help prevent the development
of infection.
 Supply the newborn with vitamin K
0.5 to 1 mg IM to prevent possible
bleeding episodes.
 Place bands on the baby carrying
mother’s name, hospital number, and
physician, and the newborn’s sex and
date and time of birth.
 Two bands are placed on the
newborn, one on the arm and one on
the leg.
 Place a matching band on the mother.
 Instruct the parents to always check
the bands when the newborn is
brought to them to ensure they are
receiving their newborn.
 Assess pain in the newborn by
observing behavior, such as crying,
sleeplessness, facial expression, and
body movements. Changes in heart
and respiratory rates, blood pressure,
and oxygen saturation.
 Swaddle and hold the infant securely
to promote comfort.
 Encourage breast feeding within 1
hour after delivery to promote
bonding and prevent hypoglycemia.
 Use non nutritive sucking on a
pacifier to comfort.
 Place sucrose on the pacifier, if
allowed by hospital policy, which
adds the benefit of analgesia suitable
for minor pain stimulus.
 Check the orders for pre procedure
pain relief methods and administer
accordingly.
 Administer immunization as per
order.
 Perform neonatal screening to
diagnose abnormalities.
 Provide individual health education
to the parents on newborn care at
home and breast feeding.

Name : B/O Age : 1 day

Anita Classification:
Newborn
Diagnosis: IP NO: 2345
Neonate
Religion: Doctor: Dr. Priya
Hindu
TPR, HR, Diet: Breast milk
RR, Spo2
Q2H