Newborn Nursing Care part 2

CHAPTER III

NEWBORN NURSING CARE

I. ASSESSMENT
Date of assessment : 20 November 2011
Assessment time : 09:00 pm

Client identity
Name : Baby Ny . S
No.RM : 512 223
Age : 1 day
Gender : Male
Time of birth : 19 November 2011 , at 17:45 am

responsible person
Mother's Name : Mrs. . S
Age : 25 years
Last Education : SD
Father's Name : Mr. . A
Age : 31 years
Last Education : SD
Occupation : Labor
Address : Kejajar

A. History of Obstetrics
1 . Parity : P2A0
2 . ANC : Historical ANC mothers do on a regular basis , six times during pregnancy . But on November 9, 2011, the client becomes swollen feet , blood pressure 160/100 mmHg , urine protein +3 .
3 . Problems during pregnancy : the client began to be detected with high blood pressure , edema of the feet , and proteinuria on November 9 , 2011. Clients experiencing nausea and dizziness during the first trimester of pregnancy , but the client does not experience blurred vision and headache .



B. History of Childbirth
1 . Type of delivery : spontaneous parturition
2 . Gestational age : 39 weeks
3 . General state of the mother : the mother 's general condition is good. Komposmentis awareness level . A. KATZ Index
4 . Birthweight : 3000 g
5 . Conditions amniotic fluid : clear amniotic fluid condition .

When circumstances Babies Born
1 ) Birth date : 19 November 2011 , at 17:45 am , the male gender .
2 ) Birth : single .
3 ) The placenta : weight ± 500 g , size : 19 x 19 x 2 cm 3 , no abnormalities .
4 ) The umbilical cord : length : ± 50 cm , the number of blood vessels 1 vein and 2 arteries , no abnormalities .

Apgar score
Value Apgar scores at birth : 7/9

sign	0	1	2	1 minute	5 minute
The frequency of heart	there is no	< 100	> 100	2	2
Enterprises breath	there is no	slow	crying strong	2	2
muscle tone	paralyzed	Limb flexion slightly	active movement	1	2
reflex	not react	little movement	reaction against	1	1
skin color	Blue / white	Reddish body, hands and feet blue	redness	1	2
		Total		7	9

1 minute Assessment : Assessment of the first minute after the baby is born with an Apgar score of 7 , in which the baby's muscle tone is still minimal limb movement , and reflexes just a little .

5th minute Assessment : Assessment with a fifth minute Apgar score 9 , which is still a bit of reflex movements .

Resuscitation :

There are no resuscitation .

Vent action : Cleanup and giving excitatory airway .

C. Posture and spontaneous motor activity

1 . Posture

Flexion posture client on all four extremities . Movement is smooth , symmetric and varied .

2 . Tone Passive on the limbs and trunk

a. popliteal angle

Less than 90o

b . Dorsoflesi Feet

The angle between the dorsum of the foot and leg anterior approach 0o

c . Signs Scarf

Prisoners strong arm . Elbow client does not reach the midline of the body .

3 . Tonus On the Extremities and Trunk Body

a. righting reaction

Upright and can withstand weight within 2 seconds .

b . Neck flexor tone

Head a little behind .

c . ventral suspension

Terekstensi head on the body , back and extremities terfleksi terekstensi .

4 . Reflexes

a. Rooting and sucking reflexes : no

b . Hand grip reflex : no

c . Grasp reflex foot : No

d . Asymmetric tonic neck reflex : no

e . Moro reflex : no

f . Stepping reflex : no

g . Reflex coughing , sneezing , blinking : no

h . Babinski reflex : flexion

D. Needs Assessment by

1 . Circumstances General

     Awareness is good, strong cry baby , skin redness

2 . Vital Signs

     Nadi : 116 x / min

    Temperature : 36.30 C

    Respiration : 48 x / min

3 . Anthropometric Measurements

     Weight : 3000 g

     Length : 46 cm

     Head circumference : 34 cm

     Bust : 33 cm

     Upper arm circumference : 12 cm

     Abdominal circumference : 33 cm

4 . The Physical Examination

a. head

Slightly oval shape , no cephal hematoma , no caput succadenum , there are no clients currently face paralise crying , black hair . Anterior fontanelle and posterior fontanelle in infants palpable soft and flat .

b . eye

Symmetrical between the right eye and the left , there is no eyelid edema , no bleeding eye , the distance between the eye canthi < 3 cm .

c . nose

There are 2 nose holes , no nostril breathing and no output secretions .

d . mouth

Mucosa moist lips , mouth no cyanosis , and there is no gap between the soft palate and the hard palate .

e . ear

There are ear canal , ear symmetry between right and left , there is no output from the ear , the ear is cut off by an imaginary line from the eye canthi .

f . neck

There is a movement of the neck , the baby's head can be bent forward , can be turned to the right / left .

g . chest

The development of regular and symmetrical chest between the right and left , the baby calm and regular breathing , no chest wall retraction , there is no use of relief O2 , breathing 48 x / minute , pulse 120 x / min .

h . abdomen

The umbilical cord was still in wet conditions , there was no pus , covered gauze , ± 4 cm long , slightly rounded belly visible , no bumps , there are bowel sounds , abdominal skin pinch < 2 seconds .

i . extremity

1 ) Fingers and toes : a complete no abnormalities

2 ) Movement : active .

3 ) there is a baby's skin is flaking superficial veins less noticeable

4 ) Lanugo only visible on the upper arm .

5 ) Baby Body felt warm .

j . genetalia

The male , the urethral meatus at the tip of the penis , no abnormalities hipospadi and epispadi , both testicles had dropped into the scrotum.

k . elimination

Assessment dated 20 November 2011 already CHAPTER 1x baby and greenish type of meconium , the baby also had BAK > 6 times / day , no abnormalities patent anus .

5 . Communications

Babies communicate with the surrounding environment by crying . Crying in infants may indicate hunger , pain , discomfort after the bowel and bladder , or dissatisfaction with breastfeeding .

6 . Stress and coping

Assessment dated 20 November 2011 , when the baby will be bathed , opened her shirt and exposed to ambient air , the baby responds by crying .

7 . Resting sleep

Babies sleeping with head facing to the right , was awakened by hunger or wetting and show it by crying .

8 . Nutrient for

Client says breastfeeding mothers and mothers were out already initiate breastfeeding . Babies fed infant when the baby was hungry , in one day the mother can breastfeed 5-10 times .

9 . Fluids

Babies get fluids or nutrition through breastfeeding

10. Elimination

	20/11/2011
defecate	1 times, soft, greenish
urination	3 times, clear

E. Assessment By Age Pregnancy (Ballard Score) 

a. Neuromuscular Maturity (attached) 

b. Physical maturity (attached)

F. Parent-Child Interaction

No.	activity	father		Mrs.
		Yes	No	Yes	No
1.	eye contact	√	-	√	-
2.	smile	√	-	√	-
3.	sound discouraging	√	-	√	-
4.	fondling	√	-	√	-
5.	Seeing the relaxed and attentive	√	-	√	-
6.	Routine visit baby	√	-	√	-
7.	Efforts exclusive breastfeeding	-	-	√	-