Immediate Physical Care

8/3/2019 Immediate Physical Care

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Presented by:Ronel S. NarcisoNR-23

Nursing Interventions:

Immediate Physical Care


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Postpartum Mother & Newborn Infant


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Immediate Care for

Postpartum Mother


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Vital Signs

Temperature

Blood Pressure

Pulse RateRespiratory Rate


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Lochia

During the first hour after birth, when the fundus ischecked every 15 minutes, evaluate also lochiacharacter, amount, color, odor, and presence ofany clots.

Clean the perineal area to avoid hardening oflochia discharged.


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Lochia

Types: Color: Days: Composition:

Lochia rubra red 1-3 Blood, fragments ofdecidua, & mucus

Lochia serosa Pink(brown-yellow)

3-10 Mucus, blood, and invadingleukocytes

Lochia alba white 10-14 Largely mucus, leukocytes

count high


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Perineum/Episiotomy

Assess the episiotomy using acronym REEDA:redness, edema, ecchymosis, dicharge, andapproximation.

Excessive edema can delay wound healing,use ofice packs is generally indicated.

Assess the rectal area for hemorrhoids, and , ifpresent, instruct the patient in hemorrhoidal

treatments. Administer analgesics as indicated.


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To provide comfort, reduce edema and promotehealing, the use of heat after this time is more

encouraged. Provide perineal /episiotomy care.

The use of heat lamp relieve pain, promote bloodcirculation, promote fast wound healing and torelieve muscle spasm.

Administer Sitz bath and giving cortisone-basecream, both decrease inflammation and relieve

tension in the area.


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Uterus

Monitor blood pressure, pulse, and respirationsevery 15 minutes for 1 hour.

Immediately after delivery of the placenta,administer oxytocin.(prevent hemorrhage)

Assess the fundus for firmness; by appro. one hourpost delivery the fundus is firm and at the level ofumbilicus.

Immediately after initiating Pitocin, massage uterinefundus until firm.


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Bladder

Bladder is nonpalpable above symphysis pubis. Assess for the return of urination, which should

occur within 6-8 hrs. of delivery. Patient should voida minimum of 150cc per void.

Encourage the woman to walk to the bathroom andvoid at the end of the first hour after birth, to helpprevent bladder distension.

Assess for signs and symptoms of a urinary tractinfection (UTI).

Encourage patients to drink adequate fluid Provide catheterization for 12-24 hour.


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Immediate Care For Newborn


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Immediate Care of the Newborn

A-airway

B-body temperature

C-check/asses the newborn

D-determined identification

E-eliminateinfection & hemorrhage


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Establish and Maintain a Patent Airway /Effective Respiration

Nursing Interventions:Wipe the mouth and nose secretions after delivery

of the head

Suction secretions from the mouth and nose

properly.Catheter Suctioning

Place head to side to facilitate drainage

Suction mouth first before nose

Period of time (5-10 secs.)

Evaluate for patency


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Stimulate the baby to cry if baby does not cryspontaneously or if babys cry is weak.

Do not slap the buttocks but rub the soles of thefeet

Do not stimulate the NB to cry unless thesecretions have been suctioned to prevent

aspiration The normal infant cry is loud & lusty. Observe for

the ff. abnormal cry:

*High-pitched cry : hypoglycemia, increased ICP*Weak cry: prematurity

*Hoarse cry: laryngeal stridor


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Oral mucus may cause the NB to choke, cough orgag during the first 12 to 18 hours of life.

Keep the nares patent.

Give O2 as needed.

If the heart rate falls below 60 bpm, cardiacmassage may need to be carried out.


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Maintain Appropriate Body Temperature

Nursing Intervention in Promoting ThermoregulationDry the neonate immediately after delivery, remove

wet towels, and place infant on warm dry towels.

Cover the neonate's head with a cotton stockingcap to prevent heat loss.

Wrap the neonate in warm blankets.

Place the neonate under a radiant heat warmer, or

place the neonate on the mother's abdomen withskin-to-skin contact.
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Provide a warm, draft-free environment for the neonate.

Nurses goal is to maintain NB temperature not less than97.7% F (36.5 C). The average NB temp.at birth is around

37.2C.NB lose heat easily because:

They have immature temp.-regulating system

Of very little amount of subcutaneous fat to provide heat

They have a larger body surface area that results in moreheat loss

They have little ability to conserve heat by changing postureand no ability to adjust its own clothing


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Methods of Heat Loss in Newborn

Convectionthe flow of heat from the newbornsbody surface to cooler surrounding air

Conduction- the transfer of a body heat to a coolersolid object in contact with a baby

Radiation the transfer of body heat to a cooler

solid object not in contact with a baby Evaporation loss of heat through conversion of a

liquid to a vapor


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Preventing Hypothermia

Dry and wrap babyMechanical pressure radiant warmer pre-heated

first isolette (or square acrylic sided incubator)

Prevent an necessary exposure cover babyCover baby with thin foil or plastic

Embrace the baby- kangaroo care

Delay initial bath until temp. has stabilized for at

least 2 hours.Maintain ambient temp. of nursery at 24C or 75F.Note the presence of any cyanosis


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Perform Initial Assessment

APGAR Scoring System Developed by Dr. Virginia Apgar in 1958

It is a standardized method for evaluation of the newbornand serves as a baseline for future evaluations.

It is taken twice: initially at 1 minute, and then at 5 minutesafter birth.

APGAR result:

0 3 = severely depressed, need CPR, admission NICU

4 6 = moderately depressed, needs additional suctioning &O2

7 - 10 =good/ healthy


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APGAR Scoring System

INDICATORS 2 1 0

Activity Active,spontaneous

Some flexion

of extremities

No movement

(flaccid, limp)

Pulse >100 bpm < 100 bpm AbsentGrimace Pulls away,

sneezes,

coughs

Facial grimace

only

No response

with

stimulation

Appearance Completely pink Acrocyanosis Bluish-gray orpale all over

Respiration Good vigorouscry

Slow, irregular

Weak cry

Absent


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Score Interpretation Nursing Interventions7 to 10 Well baby Rarely needs resuscitation

4 to 6 At risk

INFANT NEEDS

INTENSIVE CARE

Requires resuscitation

Suction

Dry immediately

Ventilate until stableCareful observation

0 to 3 Sick baby

PROGNOSIS FOR NB

IS GRAVE

Intensive resuscitation

ET/ Ambu bag

Ventilate with 100% O2

CPR

Maintain body temperature

Parental support

Score Interpretation


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Silvermann & Anderson Scoring System

Devised in 1956 and is a test used to evaluate orestimate the degrees of respiratory distress innewborns or the respiratory status of prematureinfants.

Silvermann and Anderson Scoring Interpretation:0-3 : no respiratory distress

4-6 : moderate respiratory distress

7-10 : severe respiratory distress


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The Silverman & Anderson Scoring System

0 1 2Chest Movement Synchronized

respirations

Lag on inspiration Seesaw respirations

Intercostal Retraction none Just visible Marked

Xiphoid Retraction none Just visible Marked

Nares Dilatation none minimal Marked

Expiratory Grunt none Audible by stethoscope Audible by unaided ear


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The Silverman & Anderson Scoring System

0

1

2


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0-3 No RDS

4-6Moderate RDS

7-10Severe RDS


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Proper Identification of the Newborn

Proper Id is made in the delivery room beforemother and baby are separated.

Birth certificate

A final identification check of the mother and infantmust be performed.


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Foot Printing


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Preventing Infection & Hemorrhage

Credes Prophylaxis Application of antibiotic ointment to NBs lower

conjuctival sac to prevent opthalmia neonatorum orgonorrheal conjunctivitis.

Introduced by Dr. Crede, German gynecologist in1884.

Silver Nitrate,erythromycin and tetracyclineophthalmic ointments.

Ophthalmia neonatorum

Any conjunctivitis with discharge occuring duringthe first two weeks of life.


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Administering Vitamin K

Vitamin K or aquamephyton is injected IM in thenewborns vastus lateralis (lateral anterior thigh)muscle

0.5mg (preterm) to 1 mg (full term) Vit. K.

To prevent and treat hemorrhagic disease of

newborn. Necessary for the production of certain clotting

factors.


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C f h C d


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Care of the Cord

Purposes:

To separate the umbilicus bet. The mothers placenta and

the newborns cord. To examine the three vessels (AVA)

To prevent tetanus neonatorum

The cord is clamped and cut approx. within 30 sec afterbirth. In the DR, the cord is clamped twice about 8 inchesfrom the abdomen and cut in between.

When the NB is brought to the nursery, another clamp isapplied to 1 in from the abdomen and the cord is cut asecond time.

The cord and the area around it are cleansed w/ antiseptic


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The cord and the area around it are cleansed w/ antisepticsolution.

Cord clamp is removed after 48 hours when the cord hasdried. The cord stump usually dries and falls off within 7-10

days leaving a granulating area that heals on the next 7-10days.

Leave cord exposed to air. Do not apply dressing orabdominal binder over it. The cord dries and separates

more rapidly if it is exposed to air. Report any unusual signs & symptoms that indicateinfection:

o Foul odor in the cord

o Presence of discharge

o Redness around the cord

o The cord remains wet and does not fall off within 7-10 days

o Newborn fever


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http://www.wongsworld.org/newborn/Umbico9.jpg


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Taking Anthropometrics and Other Measurements

Anthropometric Is a term which refers to a comparative measurement of the

human body.

Purposes:

Measuring head detect abnormalities of head growth. Measuring chest assure the proper development of the

chest organs and the calcification of the cartilage

Weight of a NB is done to establish baseline for monitoring

normal growth and to detect such disorder as failure tothrive and small size for gestational age.


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Assessing the Average Newborn

Head Circumference 33 35 cmTemperature 36.5-37 C (axillary)

Chest/abdomenCircumference

31 33 cm

Heart Rate 120 160 bpm

Respirations 30 60 bpm

Blood pressure 65/41 mmHg

Weight 2.5 to 3.4 kg

Length 46 to 54 cm


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Infant bath

Is a procedure done to infant for hygienic andtherapeutic purposes.

the purpose is to remove bacteria, body wastes andenvironmental contaminants from body.

It is done after delivery, to minimize changes inbody temperature of the infant.

Infant Bath


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Promoting Parenting

Show the neonate to the mother and father orsupport person immediately after birth whenpossible.

Encourage the mother and father to hold the infant

as soon as possible. Teach the mother or parents to hold the neonate

close to their faces, about 8 to 12 inches (20.5 to30.5 cm), when talking to the baby.

Have the mother or parents look at and inspect theinfant's body to familiarize themselves with theirchild.


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Cont.

Assist the mother with breast-feeding during thefirst 30 minutes, then 2 hours, after birth. This istypically a period of quiet alert time for the neonate,and he or she will usually take to the breast.

Provide quiet alone time in a low-lighted room forthe family to become acquainted.

Observe and record the reaction of the mother or

parents to the neonate.


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Thank You!!!

Oh! You havepediculosis

capitisYuck!

Dont touch!!!


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Room Lay-out

Labor Room Delivery Room


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Labor Room Lay-out

Labor room in Fabella, agovernment-run hospital inthe Philippines


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Labor Room Lay-out

Mother in the labor room.


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Labor Room Lay-out

A labor-delivery room in acertain hospital.


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Delivery Room Lay-out

Delivery room withnecessary equipment.


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Delivery buzzer is presentin some hospitals.


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Some hospitals have theseequipment in their deliveryrooms.


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Other women would like togive birth using birthingpools instead.


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Doctor and nurses indelivery room.


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Shot taken during deliveryof a baby.

D li R L


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Nurses in delivery room.

R R L


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Recovery Room Lay-out

A mother breast-feedingher twins.


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Mothers at Fabella afterdelivery.

R R L t


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Recovery Room Lay-out

A muti-patient post-operative recovery room

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Immediate Physical Care