Newborn Nursing Care part 3

II. DATA ANALYSIS

Initial client     : Baby Ny. S                           No.. CM: 512 223

Age                 : 1 day                                                 Space: Edelweiss

No.	Data Focus	Midwifery /Nursing Diagnosis	initials
1.	DS: - DO: - Babies born vaginally spontaneous-19 November 2011, at 17:45 am. - APGAR Score: 7/9 - Gestational age 39 weeks - Body color reddish when the baby is crying - Extremity palpable warmth, cyanosis (-) - Pulse: 116 x / min - Temperature: 36.30 C - Respiration: 48 x / min - BB: 3000 grams -                 - PB: 46 cm	Risk imbalance in body temperature associated with environmental temperature exposure: infant thermoregulation process of adaptation to the environment outside the uterus.
2.	DS: - DO: - There is a wound on the cord cutting - Age Baby 1 day - The umbilical cord was still wet - No pus in the cord - Umbilical cord covered gauze - Cord length ± 4 cm - Body temperature: 36.30 C -         - Water clear amniotic	The risk of infection associated with the body's primary defense is not adequate: the presence of the port de entry to the cord cutting and inadequate secondary defenses: that the baby's immune system is not adequate.

II. Nursing/Midwifery Diagnosis 

1. Risk of imbalance in body temperature associated with environmental temperature exposure: infant thermoregulation process of adaptation to the environment outside the uterus. 

2. Risk of infection associated with the body's primary defense is not adequate: the presence of the port de entry to the cord cutting and inadequate secondary defenses: that the baby's immune system is not adequate.

I.         Nursing Plan

Initial client          : Bayi Ny. S                                               No. CM           : 512223

Age                      : 1 hari                                                      Space               : Edelweis

No	Nursing Diagnosis	Objectives	Nursing interventions	initials
1	Risk imbalance in body temperature associated with environmental temperature exposure: infant thermoregulation process of adaptation to the environment outside the uterus	After the act of nursing babies for 1x24 hours to adapt to changes in environmental temperature outside the uterus with the expected outcomes: a. Body temperature within the normal range (36.5 ° -37.5 ° C) b. akral warm c. Baby skin redness d. No cyanosis	NIC Code: 6480 Environmental Management a. Pay attention to environmental temperature and also so that the baby does not directly contact cooling devices such as air conditioning / fan b. Keep the air temperature is warmer than the body temperature NIC Code: 3900 temperature Regulation a. Monitor the temperature of the baby and the baby's skin color b. Observation of the baby for signs of hypothermia (eg decrease in body temperature, pale, cold feet) c. Teach the family to keep the baby warm (for example: by providing a blanket on the baby, put the baby in a warm environment) NIC Code: 6880 Newborn Care a. Give a baby blanket to keep the baby warm temperatures b. Bathe your baby with warm water. c. Bathe the baby when the baby's body temperature has stabilized (over 8 hours)
2	The risk of infection associated with the body's primary defense is not adequate: the presence of the port de entry to the cord cutting and inadequate secondary defenses: that the baby's immune system is not adequate.	After 3x24 hour nursing actions during infection does not occur with the expected outcomes: a. There were no signs of infection (redness, fever, swelling, pus) b. Leukocytes within normal limits (5.0 X103 - X103 10.0) / uL c. Wrap the dry palpable cord a.   d. Body temperature within the normal range (36.5 ° -37.5 ° C)	NIC Code: 6540 Infection Control a. Wash hands before and take action. b. Teach client families on how to prevent infection of the umbilical cord c. Observe for signs of infection NIC Code: 6880 Newborn Care d. Dry the umbilical cord when wet e. Clean the umbilical cord is routinely f. Put the cord over the diapers and leave them exposed to the air. g. Instruct parents proper hand washing techniques before holding the baby h. Assess the umbilical cord and the area of ​​skin at the base of the umbilical cord to the presence of redness, pus or odor i. Encourage mothers to breastfeed early j. Instruct parents on how to care for the umbilical cord. NIC Code: 6530 Immunization / Vaccination management a. Give immunization in infants NIC Code: 6480 Environmental Management a. Create a bed / comfortable environment for babies a.       b. Limit visitors

To Be Continued