Nursing Interventions: Immediate Physical Care

Presented by: Ronel S. Narciso NR-23

Postpartum Mother & Newborn Infant

Immediate Care for Postpartum Mother

 Vital Signs
Temperature Blood Pressure Pulse Rate Respiratory Rate

 Lochia
During the first hour after birth, when the fundus is checked every 15 minutes, evaluate also lochia character, amount, color, odor, and presence of any clots. Clean the perineal area to avoid hardening of lochia discharged.

 Lochia
Types: Lochia rubra Color: red Days: 1-3 Composition: Blood, fragments of decidua, & mucus

Lochia serosa Pink (brownyellow)

Lochia alba white

3-10

Mucus, blood, and invading leukocytes

Largely mucus, leukocytes count high

10-14

 Perineum/Episiotomy
Assess the episiotomy using acronym REEDA: redness, edema, ecchymosis, dicharge, and approximation. Excessive edema can delay wound healing,use of ice packs is generally indicated. Assess the rectal area for hemorrhoids, and , if present, instruct the patient in hemorrhoidal treatments. Administer analgesics as indicated.

 To provide comfort, reduce edema and promote healing, the use of heat after this time is more encouraged. Provide perineal /episiotomy care. The use of heat lamp relieve pain, promote blood circulation, promote fast wound healing and to relieve muscle spasm. Administer Sitz bath and giving cortisone-base cream, both decrease inflammation and relieve tension in the area.

 Uterus
Monitor blood pressure, pulse, and respirations every 15 minutes for 1 hour. Immediately after delivery of the placenta, administer oxytocin.(prevent hemorrhage) Assess the fundus for firmness; by appro. one hour post delivery the fundus is firm and at the level of umbilicus. Immediately after initiating Pitocin, massage uterine fundus until firm.

 Bladder
Bladder is nonpalpable above symphysis pubis. Assess for the return of urination, which should occur within 6-8 hrs. of delivery. Patient should void a minimum of 150cc per void. Encourage the woman to walk to the bathroom and void at the end of the first hour after birth, to help prevent bladder distension. Assess for signs and symptoms of a urinary tract infection (UTI). Encourage patients to drink adequate fluid Provide catheterization for 12-24 hour.

Immediate Care For Newborn

Immediate Care of the Newborn

A-airway B-body temperature C-check/asses the newborn D-determined identification E-eliminate infection & hemorrhage

 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

Stimulate the baby to cry if baby does not cry spontaneously or if babys cry is weak. Do not slap the buttocks but rub the soles of the feet Do not stimulate the NB to cry unless the secretions 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

Oral mucus may cause the NB to choke, cough or gag 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, cardiac massage may need to be carried out.

 Maintain Appropriate Body Temperature

Nursing Intervention in Promoting Thermoregulation Dry the neonate immediately after delivery, remove wet towels, and place infant on warm dry towels. Cover the neonate's head with a cotton stocking cap 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 with skin-to-skin contact.

 Provide a warm, draft-free environment for the neonate. Nurses goal is to maintain NB temperature not less than 97.7% 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 more heat loss They have little ability to conserve heat by changing posture and no ability to adjust its own clothing

Methods of Heat Loss in Newborn Convection the flow of heat from the newborns body surface to cooler surrounding air Conduction- the transfer of a body heat to a cooler solid 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

Preventing Hypothermia
Dry and wrap baby Mechanical pressure radiant warmer pre-heated first isolette (or square acrylic sided incubator) Prevent an necessary exposure cover baby Cover 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

 Perform Initial Assessment

APGAR Scoring System Developed by Dr. Virginia Apgar in 1958 It is a standardized method for evaluation of the newborn and serves as a baseline for future evaluations. It is taken twice: initially at 1 minute, and then at 5 minutes after birth. APGAR result: 0 3 = severely depressed, need CPR, admission NICU 4 6 = moderately depressed, needs additional suctioning & O2 7 - 10 =good/ healthy

APGAR Scoring System

INDICATORS
Activity
Pulse Grimace

2
Active, spontaneous
>100 bpm Pulls away, sneezes, coughs

1
Some flexion of extremities
< 100 bpm Facial grimace only

0
No movement (flaccid, limp)
Absent No response with stimulation Bluish-gray or pale all over Absent

Appearance Respiration

Completely pink Acrocyanosis Good vigorous cry Slow, irregular Weak cry

Score Interpretation
Score
7 to 10 4 to 6

Interpretation
Well baby At risk INFANT NEEDS INTENSIVE CARE

Nursing Interventions
Rarely needs resuscitation Requires resuscitation Suction Dry immediately Ventilate until stable Careful observation Intensive resuscitation ET/ Ambu bag Ventilate with 100% O2 CPR Maintain body temperature Parental support

0 to 3

Sick baby PROGNOSIS FOR NB IS GRAVE

Silvermann & Anderson Scoring System Devised in 1956 and is a test used to evaluate or estimate the degrees of respiratory distress in newborns or the respiratory status of premature infants. Silvermann and Anderson Scoring Interpretation: 0-3 : no respiratory distress 4-6 : moderate respiratory distress 7-10 : severe respiratory distress

The Silverman & Anderson Scoring System

0
Chest Movement Intercostal Retraction Xiphoid Retraction Synchronized respirations none none

1
Lag on inspiration Just visible Just visible

2
Seesaw respirations Marked Marked

Nares Dilatation

none

minimal

Marked

Expiratory Grunt

none

Audible by stethoscope

Audible by unaided ear

The Silverman & Anderson Scoring System

0 1

Example

0 1

Score Interpretation
Score 0-3 Interpretation No RDS

4-6

Moderate RDS

7-10

Severe RDS

 Proper Identification of the Newborn

Proper Id is made in the delivery room before mother and baby are separated. Birth certificate A final identification check of the mother and infant must be performed.

Foot Printing

 Preventing Infection & Hemorrhage

Credes Prophylaxis Application of antibiotic ointment to NBs lower conjuctival sac to prevent opthalmia neonatorum or gonorrheal conjunctivitis. Introduced by Dr. Crede, German gynecologist in 1884. Silver Nitrate,erythromycin and tetracycline ophthalmic ointments. Ophthalmia neonatorum Any conjunctivitis with discharge occuring during the first two weeks of life.

Administering Vitamin K Vitamin K or aquamephyton is injected IM in the newborns 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.

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 after birth. In the DR, the cord is clamped twice about 8 inches from the abdomen and cut in between. When the NB is brought to the nursery, another clamp is applied to 1 in from the abdomen and the cord is cut a second time.

 The cord and the area around it are cleansed w/ antiseptic solution. Cord clamp is removed after 48 hours when the cord has dried. The cord stump usually dries and falls off within 7-10 days leaving a granulating area that heals on the next 7-10 days. Leave cord exposed to air. Do not apply dressing or abdominal binder over it. The cord dries and separates more rapidly if it is exposed to air. Report any unusual signs & symptoms that indicate infection: 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

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 to thrive and small size for gestational age.

Assessing the Average Newborn

Head Circumference Temperature Chest/abdomen Circumference Heart Rate Respirations Blood pressure Weight 33 35 cm 36.5-37 C (axillary) 31 33 cm 120 160 bpm 30 60 bpm 65/41 mmHg 2.5 to 3.4 kg

Length

46 to 54 cm

Infant Bath
Infant bath Is a procedure done to infant for hygienic and therapeutic purposes. the purpose is to remove bacteria, body wastes and environmental contaminants from body. It is done after delivery, to minimize changes in body temperature of the infant.

Promoting Parenting
Show the neonate to the mother and father or support person immediately after birth when possible. 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 to 30.5 cm), when talking to the baby. Have the mother or parents look at and inspect the infant's body to familiarize themselves with their child.

Cont.
Assist the mother with breast-feeding during the first 30 minutes, then 2 hours, after birth. This is typically 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 for the family to become acquainted. Observe and record the reaction of the mother or parents to the neonate.

Oh! You have pediculosis capitisYuck!

Dont touch!!!

Thank You!!!

Room Lay-out
Labor Room Delivery Room

Labor Room Lay-out

Labor room in Fabella, a government-run hospital in the Philippines

Labor Room Lay-out

Mother in the labor room.

Labor Room Lay-out

A labor-delivery room in a certain hospital.

Delivery Room Lay-out

Delivery room with necessary equipment.

Delivery Room Lay-out

Delivery buzzer is present in some hospitals.

Delivery Room Lay-out

Some hospitals have these equipment in their delivery rooms.

Delivery Room Lay-out

Other women would like to give birth using birthing pools instead.

Delivery Room Lay-out

Doctor and nurses in delivery room.

Delivery Room Lay-out

Shot taken during delivery of a baby.

Delivery Room Lay-out

Nurses in delivery room.

Recovery Room Lay-out

A mother breast-feeding her twins.

 Mothers at Fabella after delivery.

Recovery Room Lay-out

A muti-patient postoperative recovery room