Ferris State University School of Nursing NURS 341 Newborn Assessment Erin White

Newborn Physical Assessment Please use the following code:

+ = Present/normal

= Not present

NA = Not applicable

Admission data (This will be obtained from the babys chart!): Temp 36.7 C HR 150 Resp 58 5 min 9 Bld glucose 40mg/dL

APGAR Score 1 min 8

Resuscitation measures: delayed cord clamping, tactile

stimulation and skin to skin when stable during first breast feed Ilotycin 0249 (time) Vit K 0249 (time) Length 17.0in Wt. 6lb 4.5oz

Nursed in L&D Yes, when medically stabled

After you have read the infants chart and gathered the information, give your assessment of this infants status when it was 1 hour after birth (give details, not good)

Within an hour after birth the infants skin warm, dry, intact and no eye drainage noted. Infants lungs were clear bilaterally, regular heart rhythm and respiration rate, color consistent with race, crying & easily consoled. Anterior and posterior fontanel soft and flat, spontaneous flexion and extension of all limbs and abdomen soft and non-distended. Active bowel sounds, BM and void noted. Umbilical cord consisted of no odor, redness or drainage; cord clean & dry. NOW YOU ARE READY TO DO A PHYSICAL ASSESSMEDNT ON THIS BABY (to be completed by you the day you are caring for the baby): Temp 36.6 C Jaundice HR 140 Resp 40 Mottles Plethoric

Color: Pink: + Pale

Stained Acrocyanosis

Skin: Clear: + Pressure marks Abrasions Dry Ecchymosis Petechiae Nevi Milia Rash Lanugo Vernix + Mongolian spots Respirations: Regular: + Grunting Abdominal Retracting Shallow Nasal flaring Sighing Other NA

Cry: Lusty: +

Weak Shrill

Head: Symmerty/shape + Molding Cephalhematoma Caput succedaneum ISE mark Other NA Anterior fontanel: Flat + Full Depressed Posterior fontanel: Flat + Full Depressed Sutures Coronal Sagittal Lambdoidal Overriding Separated Approximated + + +

Ears: (describe exact location & how you determined if it was normal) Position: Normal + Skin tags Nose: Symmetry + Flaring Patent: Left + Right + Eyes: (describe what you found) Right Subconjunctive hemorrhage Nevi on lids Edema Red reflex Other Left Abnormal NA Describe normal position: midline symmetrical bilaterally.

Top of pinna noted to be in line with eyes.

Mouth: Mucous membranes: Pink + Pale Cyanotic Teeth Epsteins pearls Hard palate: Intact + Abnormal: NA Soft palate: Intact + Abnormal: NA Lips: Cleft Drooping Symmetry + Anterior chest: Symmetrical + Shape rounded Clavicles: Intact + Fracture Breasts: Palpable tissue + Engorgement

Heart sound: RRR + Other Genitals: Voided: Date 9-29-2013 Time 0216 Color of urine straw Male: Urethral orifice: Normal position + Abnormal (describe) NA Testes (#/location) 2/descended into scrotum Scrotum + Pendulous Rugated Other NA Female: Labia majora: Completely covers minora NA Partially covers minora NA Labia minora protruding NA Vaginal discharge NA Hymenal tag NA Posterior: Pilonidal dimple Truft of hair Spinal column: Symmetry + Intact + Anal patency: Yes Stool Yes Type meconium

Anterior Abd: Symmetry + Other NA Cord: # of vessels 3 Protruding base Extremities: Right Symmetry Movement Digits (number) Flexion creases Palmar creases Sole creases Hips: Intact Right Left + + Dislocated/subluxation + + 10 + + + Left + + 10 + + +

Neuro-muscular: Tone: Normal + Lethargic Rigid Tremors

Reflexes: Reflex: Describe what you observed Rooting: The newborns cheek was touched and the newborn turned toward the side that was stroked and began sucking. Sucking: The infants lips were touched and the newborn opened mouth and began sucking. Moro: Infant was startled on his own and made c-shape hands bilaterally Stroking the newborns cheek the newborn should turn toward the side that was stroked and should begin to make a sucking movement. Either place a gloved finger in the newborns mouth or touch their lips and the newborn will open mouth and elicit a sucking motion. Place newborn on their back, support upper body weight of the supine newborn by the arms using a lifting motion (without lifting off the surface) then release and newborn will startle and hands will make a c. Holding the infant upright and forward with soles of feet touching a flat surface. The newborn turns head toward side that was stroked and begins a sucking movement. Describe the procedures Describe normal responses

The infant elicits a sucking response on gloved finger or when lips are touched.

The newborn to startle arms and legs will spontaneously move and hands will make a c-shape bilaterally.

Stepping: The infant while being held with feet on the ground brought both of the feet up in stepping motion Grasp/hand: I put my finger in the infants hand bilaterally and the infant grasped my finger with his fingers Grasp/foot: I put my finger in under the infants toes bilaterally and the infant curled his toes around my finger (Ricci, 2009, 564-566).

The infant should make a stepping motion or walking, alternating flexion and extension with the soles of the feet. The newborn should grasp the finger placed in palm bilaterally.

Placing a finger on the newborns open palm. Attempting to remove finger will elicit a stronger grasp. Placing a finger on the newborns sole by the toes the newborn should grasp the finger with their toes bilaterally.

The newborn should grasp the finger placed in sole bilaterally.

What is your overall assessment and prognosis for this infant (do not say good): The infants physical assessment found the anterior and posterior fontanels were soft and flat; the sutures were approximated. The infant was alert and was aroused to sound and tactile. The infants eyes, nose, ears and mouth symmetrical bilaterally. The infants heart rate and respiratory rate was within normal limits for a newborn. The infant displayed positive reflex and neuromuscular tone was normal. The infant has active bowel sounds and passed BM and voided; the infant was circumcised. The infant is having difficulty latching to mothers breast during feedings and the RN is working alongside the mother to assist with solutions.

On the basis of your assessment, list at least TWO nursing diagnosis for this baby and all the teaching interventions you would use for each nursing diagnosis. Please include the rationale for your actions. You must have at least two references besides your textbooks for your rationales. Be sure your assessment and interventions correspond to your Nursing Diagnosis.

Nursing Diagnosis
Ineffective breastfeeding r/t poor infant latch on mothers nipple.

Necessary Assessments/Interventions
1) Observe a full breastfeeding session (every 8 hours in the early postpartum and once per visit on follow-up). 2) Evaluate the breast and nipple structures and provide appropriate measures as needed. 3) Encourage rooming-in and feeding on demand. 4) Initiate breastfeeding follow-up after hospital discharge. 1) Collect data and monitor signs of adequate infant intake/nutrition. 2) Promote comfort and relaxation to reduce pain and anxiety. 3) Avoid supplemental feedings. 4) Assist the client to identify and utilize support network. 5) Initiate a visit with a lactation specialist.

Rationale
According to the Annals of Internal Medicine, Breastfeeding interventions can include a combination of individual components, such as structured breastfeeding education or professional or lay support (Chung, Raman, Trikalinos, Lau & Ip, 2008). Assessing the patient and infants bond during a breastfeeding session will allow the professional to assist with proper feeding techniques. According to the Canadian Medical Association Journal a nurse or lactation specialist to assist patient with difficulty breastfeeding increases a postpartum womans experience. These interventions, consisting of individual or group instruction about breast-feeding knowledge, practical skills and problem-solving techniques, were effective when provided by lactation specialists or nurses, and both single sessions and multiple sessions were effective. Postpartum telephone or in-person support by lactation specialists, nurses or peer counselors enhanced the effectiveness of these interventions (Palda, Guise & Wathen, 2004).

Risk for imbalanced nutrition r/t difficult latching with breastfeeding aeb mother states he isnt latching correctly.

Reference Ackley, B. J., & Ladwig, G. B. (2004). Nursing diagnosis handbook: A guide to planning care. (6th ed.). St. Louis, Missouri: Mosby. Chung, M., Raman, G., Trikalinos, T., Lau, J., & Ip, S. (2008). Interventions in primary care to promote breastfeeding: An evidence review for the u.s. preventive services task force. Annals of Internal Medicine, 149(8), 568-570. Retrieved from http://www.uspreventiveservicestaskforce.org/uspstf08/breastfeeding/brfeedart.pdf Palda, V. A., Guise, J. M., & Wathen, C. N. (2004). Interventions to promote breast-feeding: applying the evidence in clinical practice. Canadian Medical Association Journal, 170(6), 976-978. Retrieved from http://www.cmaj.ca/content/170/6/976.full Ricci, S.S. (2009). Essentials of maternity, newborn, and women's health nursing. (3rd ed.). Philadelphia, PA: Lippincott, Williams and Wilkins.