Question

Nursing care plan.

Baby girl Destiny was born by cesarean delivery 2 days ago. Destiny weighed 7 pounds 3 ounces, length 19 inches, head circumference 34 cm, chest circumference 34 cm. Her newborn course has been unremarkable. You observe that when held, Destiny appears alert and stares into her caregiver's face. Destiny appears to be a content baby and cries only when she is hungry or when she needs a diaper change. When hungry, you observe that she brings her hand to her mouth and starts sucking on her fist and then begins to cry. Destiny falls asleep immediately after the feeding. The telephone, which is next to Destiny on her mother’s bed, rings loudly and Destiny does not appear to respond to the loud sound by moving her extremities or awakening briefly.

a. What are the common Sign/Symptoms?

b. What are the potential complications?

c.What are the expected Assessment Findings head to toe?

d. All NANDA nursing diagnosis.

Answer 1

a.)answer

New born are even able to hear when they are inside the womb of their mothers, they can hear each and every sound produced by mother like , belching, gargling, sound of food digestion, etc.

Baby's ear are well developed at the time of birth but it may take 4 to 6 months to hear and respond to sound clearly .

When a baby is not responding to loud sound then it may be because of various reasons.

1. Presence of fluid in the baby's ear , which decreases gradually .

2. The part of brain is still developing which takes part in hearing.

Sign and symptoms are.

1.Doesn respond to loud noise.

2. Not get calmed by low sound.

3. Doesn't wakeup by sudden noise while sleeping.

b) answer:

Complications can be;

1. Innate complications like herpes, rubella, toxoplasmosis, oxygen deficiency.

2. Disorder of brain or nervous system problem.

3. Use of certain medication by mother during pregnancy like ototoxic drugs, non steroid anti inflammatory drugs can cause hearing loss.

4. Maternal Increased glucose level during pregnancy.

5. Smoking and drinking alcohol in pregnancy.

Head to toe assessment of new born.

It starts with weighing baby average weight of newborn is 7 pounds and length 20 inches , head is 35 cm and chest is 33 cm at birth and by reading destiny's assessment all are in normal range .

1.Skin: Color of skin is noted , skin appears reddish and fingers and toes appear slightly blueduring few hours after birth.

2. Head , neck and face : head , neck and face are examined to check any abnormalities, birth defect may be present.

Head are examined for shape (normocephalic) ,caput succinadum , hydrocephalus, cerebral hematoma, etc.

Neck is examined to check twist , swelling, and abnormal mass growth.

Face is examined for symmetry , it may be asymmetrical due to pressure , which recovered gradually.

Ears: ears are checked to know any genetic disorders or hearing loss, misaligned ear may cause hearing loss.

Mouth is checked for cleft lip and cleft palate , which makes feeding and sucking difficult.

Heart and lungs: heart murmur and congestion may reveal some congenital defect of heart and lungs, breathing and pulse also appears abnormal due to defect in heart and lungs.

Abdomen and genitals: abdomen and genitals are checked to know birth defects such as shape, size and positions by palpation.

Genitals are checked for hypospadias and no of openings in female ( urethral and vaginal opening) .

Nervous system

It is checked for spinal cord defect and brain defect , it reveals alertness, muscle tone, equal mivememoof legs and hands, unequality may reveal abnormality .

Reflexes are checked such as rooting reflex, sucking reflex, grasping reflex, moro reflex, etc.

Muscles and bones:

Flexible arm , legs and muscles are examined .

Nursing diagnosis are(NANDA)

1. Disturbed sensory perception related to change in environment / hearing loss as evidenced by no response to loud sound .

2. Risk for infection related to low immunity .

3. Impaired skin integrity relate to related to external factors such as diaper rash , heat rash etc.

4. Risk for imbalanced nutrition less than body requirements related to gradual weight loss.

5. Risk for hypothermia related to entry on external world .