Maternal and Child Health Nursing Care of High-Risk Newborns PDF

MATERNAL AND CHILD HEALTH NURSING FINAL TRANSES NURSING CARE OF THE HIGH-RISK NEWBORN NURSING PROCESS OVERVIEW...

MATERNAL AND CHILD HEALTH NURSING FINAL TRANSES NURSING CARE OF THE HIGH-RISK NEWBORN NURSING PROCESS OVERVIEW DIAGNOSIS WEEK 8 Ineffective airway clearance related to the presence of mucus or amniotic fluid in the airway OUTLINE Ineffective tissue oxygenation related to breathing difficulty Ineffective thermoregulation related to immature status I. Problems related to maturity Risk for deficient fluid volume related to insensible water loss a. Pre-maturity Risk for imbalanced nutrition, less than body requirements, 1. New Ballard Test related to the lack of strength for effective sucking b. Post-mature Risk for infection related to lowered immune response due to c. Small for gestational age prematurity Risk for impaired parenting related to illness in newborn at birth d. Large for gestational age Deficient diversional activity (lack of stimulation) related to illness e. Acute neonatal conditions at birth 1. Respiratory distress syndrome Readiness for developmental care to decrease overstimulation f. Meconium easily caused by necessary lifesaving procedures 1. Aspiration syndrome g. Neonatal sepsis Note: To establish nursing diagnoses for high-risk infants, it is important h. Hyperbilirubinemia to be aware of the usual parameters of newborns. i. Sudden infant death syndrome NURSING PROCESS OVERVIEW PLANNING PROBLEMS RELATED TO MATURITY ✓ Be certain when establishing expected outcomes that INTRODUCTION they are consistent with a newborn’s potential. A goal that implies complete recovery from a major During pregnancy, screening women for risk factors illness, for example, may be unrealistic for one such as younger or older than average maternal age, newborn but completely appropriate for another. having concurrent disease conditions such as ✓ Be certain plans for care are individualized diabetes or HIV infection, experiencing pregnancy considering a newborn’s developmental level as well complications such as placenta previa, or an as physiologic strengths, weaknesses, and needs. unhealthy maternal lifestyle such as drug abuse all of Many families of a high-risk newborn will need which could lead to illness in a newborn is essential support to care for their infant at home and to identify infants who may need greater than usual therefore may need a referral to a home health care care at birth. or other agency NURSING PROCESS OVERVIEW NURSING PROCESS OVERVIEW ASSESSMENT PLANNING ✓ Obvious congenital anomalies and gestational age Interventions for any high-risk newborn are best carried ✓ First assessment is done under a prewarmed radiant heat out by a consistent caregiver and should focus on warmer conserving the baby’s energy and providing a ✓ Continuing assessment: cardiac, apnea, oxygen saturation, thermoneutral environment to prevent exhaustion and and blood pressure monitoring. hypothermia. Painful procedures should be Common sense observations by a nurse: kept to a minimum to help the infant achieve a sense of Carefully evaluate comments from fellow nurses such as an infant comfort and balance. “isn’t himself” or “breathes irregularly.” Assisting parents to participate in care such as bathing or feeding their infant can help These comments, although not evidence based, are the same make the child real to them for the first time and can set observations that parents who know their baby well report at the stage for effective bonding. healthcare visits. SALAZAR, CATHLYN L. NUR228  NURSING PROCESS OVERVIEW HOW SHOULD A BABY'S SKULL FEEL? OUTCOME EVALUATION Your baby's fontanelle should feel soft and flat. If you Infant maintains a patent airway. softly touch a fontanelle, you may at times feel a slight Infant demonstrates an ability to suck effectively. pulsation due to blood flow in the blood vessels around Infant tolerates procedures without accompanying the brain this is normal. apnea, bradycardia, or oxygen desaturation. Premature babies, who are born before the full term of Infant demonstrates growth and development pregnancy, are at a higher risk of developing ear appropriate for gestational age, birth weight, and deformities. Their ear cartilage might not have had condition. enough time to fully harden and take its final shape Infant maintains a body temperature of 98.6°F before birth. This can result in baby ears that appear (37.0°C) in an open crib with one added blanket. folded or misshapen. Parents visit at least once and make three telephone calls to the neonatal nursery weekly. COMMON FACTORS (PRETERM BIRTH) Parents demonstrate positive coping skills and Low socioeconomic level behaviors in response to the newborn’s condition Poor nutritional status and ability to care for their newborn Lack of prenatal care Multiple pregnancy PRE-MATURITY Previous early birth WHAT IS PREMATURITY Race (non-Whites have a higher incidence of prematurity Babies born more than 3 weeks earlier than their than Whites) expected due date are called "premature." Premature Cigarette smoking babies (preemies) didn't have enough time to grow and Age of the mother (highest incidence is in mothers age develop as much as they should have before birth. Term