NUR 323 Health Promotion Newborn Care _4_.docx

NUR 323 Health Promotion Newborn Care _4_.docx - West...

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West Liberty University NUR 323 Health Promotion of Newborn Study Guide for 4/20/18 Reading Assignment: Perry & Hockenberry pp 529-634 Objectives: 1. Discuss nursing care for newborns in the immediate timeframe after birth 2. Describe potential alterations in respiratory status and thermoregulation problems of the newborn and nursing interventions to decrease complications 3. Nursing Care from Birth through the first 2 hours Primary goal after birth is to assist the neonate to successfully transition to extra-uterine life Establish effective respirations by: Vigorously dry infant (removes moisture and prevents heat loss through evaporation o For the first 10 seconds If they go beyond this, more intense interventions need to be done Delay cord clamping – after this the 1 minute APGAR will be done If it doesn’t seem like the baby will pink up they will not facilitate the delayed cord clamping Remove wet linens o Evaporation heat loss Cap on newborn’s head Diaper o Might not put on as long as skin to skin with mom, as discretion of mom, but do not want them wet because they could lose heat again Skin to skin with mom Cover with warm blanket Place infant under warmer if infant is not term, has poor muscle tone or is not crying or breathing. If infant is apneic or has gasping respirations positive pressure ventilation is needed. Assess heart rate by grasping base of umbilical cord or auscultation. Should be greater than 100. - Some part of recussitation process may need to be done it may not need to be full CPR - Apneic will score a 0 for respirations o May need PPV Face mask on infant and forces mucous out of alveoli o If they are fine after that skin to skin is okay to facilitate - Listen for 6 seconds and multiple by 10 to get heart rate because it is a life saving moment
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See Neonatal Resuscitation Algorithm-2015 update page 556 If not pinking up after oxygen administration then you will check the seal on the mask and redo it because usually they will pink up after this administration Nursing Diagnosis Ineffective Airway Clearance related to excessive cheek secretions in airways. Planning Expected Outcomes 1. Will maintain a patent airway and show no signs of respiratory distress throughout the birth facility stay as demonstrated by respiratory rates of 30 to 60 breaths per minute, clear breath sounds, and no cyanosis, retractions, flaring, or grunting. 2. Before discharge, parent will demonstrate correct use of the bulb syringe and verbalize when it should be used. Interventions and Rationales 1. Position the infant’s head to the side to allow secretions to pool in the cheek and suction with a bulb syringe as needed. If the nose also needs suctioning, suction it gently because suctioning can traumatize the delicate nasal tissues. Suction the mouth first to avoid aspiration if the infant gasps when the nose is suctioned.
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  • Spring '14
  • DianeM.Tomasic
  • Respiratory distress, Blood sugar

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