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Example Care Plan_Newborns (Cheat Sheet)
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Newborn Assessment – Condensed (Cheat Sheet)
Newborn Assessment (Cheat Sheet)
Newborn Assessment – APGAR Score (Image)
Newborn Assessment (Picmonic)
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Transcript
Hey everyone. Today, we're going to be creating a nursing care plan for newborns. So let's get started. First, we're going to go over the pathophysiology. So relating to the period immediately succeeding birth is continued to the 28 days of extra uterine life is considered to be newborn. Nursing considerations: immediate postpartum assessment, assisting with breastfeeding, assessing daily weight, educating mother and family on newborn care, and discharge teaching. Desired outcome: the newborn will feed properly and have normal vital signs, proper elimination patterns, and be free from infection. Caregivers will be properly educated on newborn care and signs and symptoms of when to call the physician.
So we're going to go ahead and get started on a care plan. We're going to be listing out some subjective data and some objective data. Some newborn subjective data: you tend to see them crying, especially early on. Some objective data: going to make sure that these babies have normal vital signs, their reflexes are intact, and their skin is intact. We want to make sure that they are gaining weight properly as well.
Interventions are what we're going to do for newborns. This is going to be for the immediate needs of a newborn from the moment that they are born. So we're going to talk about some of the immediate needs, right when they're born. So one of the first things is aspiration. The mucus. You're going to be doing an APGAR score, and that is based on the heart rate, respiratory effort, muscle tone, reflex ability and the skin color. We're going to also maintain body temperature. So the drying, making sure that the newborns are wearing a hat, and having a warm blanket. We're going to be doing eye care and doing injections. So we're going to be applying that erythromycin ointment, a vitamin K injection and a Hep B injection. We're going to make sure we're doing constant observation of the newborn. We're going to be applying ID bands. So we're going to be putting one on the wrist, one on the ankle. We’re also going to make sure we're clearing the baby's airway of mucus. The APGAR score is the cardiorespiratory adaptation at birth. The body temperature; we want to make sure we're preventing acidosis, hence the warm blankets and the warm hat. Hep B injection. We want to make sure that we are giving this and the vitamin K injection. We both are giving in the muscle. The baby and the parents will be tagged for having access. Another intervention we're going to be doing. We're going to be doing a full head to toe assessment. So after the baby's born, we're going to do this full assessment. So we're going to do a general appearance. We're going to be checking the reflexes and doing vital signs. So we're going to be looking at the umbilical cord. If they have anything like a Mongolian spot, and the shape of the head, if they have a cleft lip or a pallet, we're going to be looking for those things. Reflexes; we're going to be looking for rooting, sucking, grasping, startle, moro, babinski, and the tonic neck reflex all to which we want to make sure we're assessing as all of these are the first building blocks. So the first development of a newborn. So what starts out as reflexes are going to soon turn into per purposeful cognitive and physical activity. Another intervention that we're going to be doing, we're going to assist with breastfeeding. So we're going to be helping the mom with breastfeeding. We're going to get a lactation consultation. If we're needing help with the mom and able to get the baby latched. If they're not latching properly, we want to make sure we're getting that lactation consultation to help assist with the baby to make sure that the baby gets the proper nutrition. Another intervention, we want to make sure that we're assessing that newborn weight daily. So daily weights. After the mother's milk comes in, the newborn should be starting to gain some weight. It's normal for them to lose about 5%, five to 10% of their weight. Within the first few days, if the newborn isn't gaining weight at all, there could be a feeding issue or any other problem that we need to look into. Another intervention that we want to be doing is a lot of education. So education, we want to make sure that we are educating on elimination patterns, circumcision for males and bathing. So within the first 24 hours there should be a wet diaper and one stool. By day three, there should be three to four wet diapers and one to two stools. And the change from the meconium to that yellowish color on day four, after the milk has come in, there should be greater than 6 to 8 wet diapers and three stools per 24 hours. For circumcision, the main complication is hemorrhage and infection, glucose water on a pacifier and use of petroleum jelly on the site for circumcision. We want to make sure the newborn is taking in enough nutrients and having normal elimination patterns with no complication prior to discharge home. Note, after the male circumcision is complete, we want to make sure that they have voided prior to discharge for bathing. We want to main things with bathing. You want to make sure that the baby's axillary temperature is warm enough and to check the water temperature with your inner full or arm. Another intervention that we want to be doing is newborn discharge teaching. So we're going to be doing some discharge teaching. And when to call the physician, once the family's home with the newborn; it's important to educate them on when it's appropriate to call the doctor or to be seen right away for any sort of complications that may arise. The newborn genetic testing we're going to want to be doing prior to discharge, as well as a hearing and pulse screening. So for genetic testing, that includes PKU, hypothyroidism, urine disease, sickle cell anemia, and Tay Sachs disease. Some blood tests that screens from multiple genetic and metabolic disorders are done at discharge and repeated at seven to 10 days of age. Hearing screening. We, you want to see if the infant has any sort of deficits like heart of hearing, or if they're deaf and with the pulse screenings, which is typically 24 to 48 hours, we want to detect if the baby might have CCHD or critical congenital heart disease.
All right, so now we're going to head on to the key points. So newborns are relating to the period immediately succeeding birth and continuing through the first 28 weeks of extra uterine life. Newborns come from within the mother's womb via vaginal birth, or C-section. Some subjective and objective: babies or newborns do cry, normal vital signs, weight gain, reflexes that are intact, newborn resting comfortably, and their skin that's intact. You want to make sure we're doing an immediate assessment post birth, head to toe assessment, assisting with breastfeeding and assessing newborn weight daily, educating on the newborn elimination patterns, feedings, circumcision for males, baths, genetic testing at discharge, hearing screen and pulse screening. Important to have all this education, especially at discharge. And that is the end of that care plan.
You guys did amazing. We love you. Go out, be your best self today, and as always happy nursing.
So we're going to go ahead and get started on a care plan. We're going to be listing out some subjective data and some objective data. Some newborn subjective data: you tend to see them crying, especially early on. Some objective data: going to make sure that these babies have normal vital signs, their reflexes are intact, and their skin is intact. We want to make sure that they are gaining weight properly as well.
Interventions are what we're going to do for newborns. This is going to be for the immediate needs of a newborn from the moment that they are born. So we're going to talk about some of the immediate needs, right when they're born. So one of the first things is aspiration. The mucus. You're going to be doing an APGAR score, and that is based on the heart rate, respiratory effort, muscle tone, reflex ability and the skin color. We're going to also maintain body temperature. So the drying, making sure that the newborns are wearing a hat, and having a warm blanket. We're going to be doing eye care and doing injections. So we're going to be applying that erythromycin ointment, a vitamin K injection and a Hep B injection. We're going to make sure we're doing constant observation of the newborn. We're going to be applying ID bands. So we're going to be putting one on the wrist, one on the ankle. We’re also going to make sure we're clearing the baby's airway of mucus. The APGAR score is the cardiorespiratory adaptation at birth. The body temperature; we want to make sure we're preventing acidosis, hence the warm blankets and the warm hat. Hep B injection. We want to make sure that we are giving this and the vitamin K injection. We both are giving in the muscle. The baby and the parents will be tagged for having access. Another intervention we're going to be doing. We're going to be doing a full head to toe assessment. So after the baby's born, we're going to do this full assessment. So we're going to do a general appearance. We're going to be checking the reflexes and doing vital signs. So we're going to be looking at the umbilical cord. If they have anything like a Mongolian spot, and the shape of the head, if they have a cleft lip or a pallet, we're going to be looking for those things. Reflexes; we're going to be looking for rooting, sucking, grasping, startle, moro, babinski, and the tonic neck reflex all to which we want to make sure we're assessing as all of these are the first building blocks. So the first development of a newborn. So what starts out as reflexes are going to soon turn into per purposeful cognitive and physical activity. Another intervention that we're going to be doing, we're going to assist with breastfeeding. So we're going to be helping the mom with breastfeeding. We're going to get a lactation consultation. If we're needing help with the mom and able to get the baby latched. If they're not latching properly, we want to make sure we're getting that lactation consultation to help assist with the baby to make sure that the baby gets the proper nutrition. Another intervention, we want to make sure that we're assessing that newborn weight daily. So daily weights. After the mother's milk comes in, the newborn should be starting to gain some weight. It's normal for them to lose about 5%, five to 10% of their weight. Within the first few days, if the newborn isn't gaining weight at all, there could be a feeding issue or any other problem that we need to look into. Another intervention that we want to be doing is a lot of education. So education, we want to make sure that we are educating on elimination patterns, circumcision for males and bathing. So within the first 24 hours there should be a wet diaper and one stool. By day three, there should be three to four wet diapers and one to two stools. And the change from the meconium to that yellowish color on day four, after the milk has come in, there should be greater than 6 to 8 wet diapers and three stools per 24 hours. For circumcision, the main complication is hemorrhage and infection, glucose water on a pacifier and use of petroleum jelly on the site for circumcision. We want to make sure the newborn is taking in enough nutrients and having normal elimination patterns with no complication prior to discharge home. Note, after the male circumcision is complete, we want to make sure that they have voided prior to discharge for bathing. We want to main things with bathing. You want to make sure that the baby's axillary temperature is warm enough and to check the water temperature with your inner full or arm. Another intervention that we want to be doing is newborn discharge teaching. So we're going to be doing some discharge teaching. And when to call the physician, once the family's home with the newborn; it's important to educate them on when it's appropriate to call the doctor or to be seen right away for any sort of complications that may arise. The newborn genetic testing we're going to want to be doing prior to discharge, as well as a hearing and pulse screening. So for genetic testing, that includes PKU, hypothyroidism, urine disease, sickle cell anemia, and Tay Sachs disease. Some blood tests that screens from multiple genetic and metabolic disorders are done at discharge and repeated at seven to 10 days of age. Hearing screening. We, you want to see if the infant has any sort of deficits like heart of hearing, or if they're deaf and with the pulse screenings, which is typically 24 to 48 hours, we want to detect if the baby might have CCHD or critical congenital heart disease.
All right, so now we're going to head on to the key points. So newborns are relating to the period immediately succeeding birth and continuing through the first 28 weeks of extra uterine life. Newborns come from within the mother's womb via vaginal birth, or C-section. Some subjective and objective: babies or newborns do cry, normal vital signs, weight gain, reflexes that are intact, newborn resting comfortably, and their skin that's intact. You want to make sure we're doing an immediate assessment post birth, head to toe assessment, assisting with breastfeeding and assessing newborn weight daily, educating on the newborn elimination patterns, feedings, circumcision for males, baths, genetic testing at discharge, hearing screen and pulse screening. Important to have all this education, especially at discharge. And that is the end of that care plan.
You guys did amazing. We love you. Go out, be your best self today, and as always happy nursing.
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