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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Score Interpretation
Score Interpretation
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 Room Lay-out
Delivery buzzer is presentin some hospitals.
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Delivery Room Lay-out
Some hospitals have theseequipment in their deliveryrooms.
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Delivery Room Lay-out
Other women would like togive birth using birthingpools instead.
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Delivery Room Lay-out
Doctor and nurses indelivery room.
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Delivery Room Lay-out
Shot taken during deliveryof a baby.
D li R L
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Delivery Room Lay-out
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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