FUNDAMENTALS OF NURSING

NURSING PROCESS : a tool in Caring a patient; Steps; Problem Solving approach. **Assessment Collection of data; purpose is to get a BASELINE DATA; to identify problem and needs; Basis of Diagnosis; Basis of Nsg. Intervention. Must be truthful and accurate. *basis and verification*

Guides: Gordons Theory of Nursing Assessment. Goal: Check the functional ability of the organs. 2 types of data: 1. SubjectiveSymptoms/Covert/Qualifiable; perceive by client alone. 2. ObjectiveSigns/Overt/Quantifiable; can be verified by the Nurse; can be measured. Sources: 1. Primarypatient alone. (infantmother) 2. Secondarysignificant others; relatives; Nurses; records. Methods of Collecting Data: 1. Interview 2. Observe 3. Physical assessment Techniques used in collecting data: Therapeutic Technique 1. Establish rapport 2. Communication skills-- (Open Ended QuestionsTherapeutic C.) a. Closed Ended Q. will give short answers yes/no. b. WHY-> Proving question. c. Statements that gives False reassurance. d. Statements that gives Advise/Judgement. 3. ReflectingRephrase the question back to the pt.; to confirm let the pt. elaborate. Reasons not allowed to touch pt: 1. Paranoids/Schizophrenia 2. Assaultive pts. 3. Burn pts.(Because risk for Infections) Observation : 4 senses (except Taste) *IPPAChest; Heart *IAPPAbdomen

Reasons why IAPP in Abdomen: (Accdg to. Maam Fernandez) 1. Manipulation will alter the bowel sounds 2. Pain will be elicited; P.A will be delayed Reasons Accdg to Sir Barlahan: 1. WILMS Tumor (adenocarcinoma, to prevent metastasization) 2. Abdominal Aortic Aneurism (to prevent Rupture) Rebound tendernesspain is not elicited, when finger is removed pain is present. INSPECTIONalways provide a good lighting(best is SunlightNON FLOURESCENT LIGHT) Inspect for Size, shape, Color, Texture, Symmetry, Position**

Colors:

YellowJaundice GrayPallor

BlueCyanosis RedFlushed BelowInferior Towards theMedial;Center

Positions: AboveSupra Away fromLateral;Distal

PALPATIONwarm hands; rub together for FRICTION. Palpate for Masses, Pulsation, Organ size, Tenderness/pain, Swelling, Tissue fullness/elasticity, Vibration, Crepitus, Temperature, Texture, Moisture. Breastalways starts at Upper Outer Quadrant. Abdomeninverted U. Periarticular Nodes:Fingertips. Temperature: Dorsum of hand. Vibration at back(99): Palm or Ulnar edge of hand. *Light(1) to Deep(beyond 2) Palpationto assess presence of Tenderness. *Bimanual Palpationto assess movable structures(non dominant handsensing hand) *Ballottementto check for ASCITES (fluid within abdominal cavity). PERCUSSION -- to determine Size, location, Density of tissues; Pain in areas up to depth of 3-5cm(1-2). Types: DirectBrisk; strike body part with 1-2 fingers. IndirectHand placed over body surface. Bluntuse of Reflex Hammer to check DEEP TENDON REFLEX (DTR). Blunt with FistTo assess Costovertebral Angle (CVA). FLEXORSStriking Hand FLEXIMETERStationary Hand

Sounds produced: Resonance-------------*mod. to loud low pitch, clear & hallow, airfilled tissues (LUNGS). Hyperresonance----*loud to low pitch with longer duration, inflated airfilled tissues. (N in Children-- thin chest wall; Adultpulmonary emphysema) Dull----------------------*mod. to high pitch, soft muffled, dense fluid tissue (LIVER & HEART). Tympany--------------*loud high pitch, drumlike musical sound, enclosed airfilled structures. (Bowel; Collic abdomen). Flat----------------------*high pitch sound of shorter duration, very soft, dense tissues. (Bones &muscles). R sided HeartDEXTROCARDIA AUSCULTATION-- listen over bare skin; moisten body hair to prevent crackling sounds. Stethoscope: Diaphragmhigh pitch sound (Lungs & Bowel). Placed FIRMLY.(Taking of BP for Obese pts.) Belllow pitch sound (Heart). Placed LIGHTLY. (Taking of BP)

General Survey: (physical/emotional/mental/psychological/LOC)

**Height/Weight: Men----------(106 Ibs for 15 ft + 6 Ibs/inch.) Women------(105 Ibs for 15 ft + 5 Ibs/inch.)

Cephalocaudal Assessment/ Proximodistal Assessment: A)

(S C H E E N T S C H B A E G

Skin Pink (TEA ROSE)

YellowJaundice(Hyperbilirubinemia; Clay FecesObstructed Bileduct) **Physiologic JAfter 24-48hrs; RBC(120days)end productsBilirubin **Pathologic J1st 24hrs; Blood Incompatibility: Mother is O Baby is A/B Mother is RH(-) Baby is RH(+) 1. Check Blood type of father. 2. Request for COOMBS test. 3. RHOGAM Check ->(Nail beds, Oral mucosa, Sclera) BlueCyanosis (AcrocyanosisN at Newborn) **Hypoxia-- dec. O2 in Tissues ;1st sign Restlessness-Late sign Cyanosis) BRAIN (Suctioning) ** Hypoxemiadec. O2 in Blood; 1st sign Tachycardia-Late sign Bradycardia) HEART (Hypovolemia) GrayPallor(Anemiadec. RBC/Hgb; Vasoconstriction of blood vessels) Check-> Lightingnon flourescent light (Buccal mucosa & Conjunctiva) RedFlushed(Polycytheniainc. Number of RBC; VasodilationFever; low BP) *Infant70% of water (dewish skin) MacularFlat PapularElevated *Adult55% of water *Elderly45% of water Postularwith Pus Vesicularwith fluid

Depth of Edema: +1-2mm, +2-4mm, +3-6mm, +4-8mm (Hand Vein Test) Degree of Edema: +1- Ankles, +2- Knees, +3- Groin, +4- Generalized Edema(Anasarca). Homans signThrombophlebitis; Dorsiflex the feet (if there is pain in the Calf(+)) *Peripheral EdemaR sided Heart failure; venous congestion *Pulmonary EdemaL sided Heart failure

NailsCapillary refill Test (<7sec.poor capillary refill test)

Colors: Infections) ***(Dx: Altered tissue Perfussion)*** PinkNormal White PinkKidney Problem WhiteAnemic GreenPseudomonas Infection(Nosocomial YellowJaundice Red Violet-- Traumatized Black-- Malaria

HairHirsuitism (excess);

Alopecia(Loss/Thinning)

Inspect & Palpate (presence of Nevus/Moles)

HeadInspect & Palpate (Neuro Problems) FaceInspect/Palpate/Percuss(Sinuses)

EyesInspect/Palpate; Visual field/Visual Acuity (SNELLENS CHART N- 20/20)

Pupil Equal Round Reactive to Light and Accommodation (PERRLA) PupilConstrict(react to LIGHT) Periphery towards the center; pinpoint size; 3-7mm in diameter. Dilate(Accommodation) Near and Far; 10mm in diameter. Photophobialight Intolerance 120/20Myopia/Nearsightedness AstigmatismDistorded Vision Nystagmus--Involuntary Eye Movement one Eye(Lazy Eye) 20/120-- Hyperopia/farsightedness PtosisDrooling of eyelids StrabismusInvoluntary drifting of

EarsInspect/Palpate; WEBERS TEST/RHINES TEST(assess Bone Coneduction); TUNING

FORK(vibration 2:1) 3y/o belowPull Pinna down and backward ; 3y/o abovePull Pinna up and backward 5 oclockR to L ; 7 oclockL to R (To find Tympanic Membrane).

NosePalpate/Percuss
Parkinsons position--Maxillary&Frontal Proetz positionEthmoid&Sphenoid 6y/o: 1st permanent teeth 12-13y/o: 2nd Molar 14y/o: 28 teeth

Mouth&Pharynx

5y/o: 20 teeth 7y/o: 24 teeth 13y/o: 2nd set errupt Adult: 32 teeth

Throat/Neck/TracheaInspect/Palpate; Endocrine Problems; NeckPt. is

sitting&examiner behind. *Neck Vein EngorgementElevate at angle of 35-40 degrees. Jugular vein; Normally distended.

SpineInspect/Palpate; Anteroposterior = Transverse

Diameter (1:2/5:7)ADULT; AP diameter = Chest Diameter (1:1)INFANT; Kyphosis: Dowahgers Hump Lardosis: Scoliosis: Bend Forwardcheck for Lumbar curve

Sittingcheck for Thoracic curve

ChestIPPA ;
Barel: COPD Pigeon: Funnel: Rales/Crackles: Pleural friction Rub: Rhonchi/Wheezes:

Tactile Fremitusvibration; Ulnar edge/base (99) N >Bronchopony Say E and hear A >Egophony Vesicular:

Bronchovesicular: Bronchial:

Heart&VesselsIPPA;

S1 Lubb: Closure of tricuspid and mitral valves S2 Dubb: Closure of the aortic and pulmonic valves R & L 2nd ICS along SternumAortic&Pulmonic 5th ICSTricuspid 5th ICS, Midclavicular LineMitral/ Point of Maximum Impulse. Murmursturbulence within heart valves. Pulse deficitDeifference between apical and radial. R sided failureperipheral edema L sided failurepulmonary edema

9 Pulse SITES: 1. Temporal PulseSuperior Lateral Eyes. 2. Carotid PulseSide of the Neck, Angle of Jaw. 3. Apical Pulse5th ICS Midclavicular Line. 4. Brachial PulseMedial to the Antecubital Fossa, along side of Small finger. 5. Radial PulseWrist, Along side of the Thumb. 6. Femoral PulseMiddle of Groin. 7. Popliteal PulseBehind the Knee, Slightly flex Knee. 8. Posterior TibiaMedial, above the Malulus, Below Tibia. 9. Dorsalis PedisAbove instep, above Dorsum, between the big and 2nd Toe.

BreastInspect/Palpate; always starts at Upper Outer Quadrant. Supine with arms raised.
Gynecomastiabreast enlargement in males.

AbdomenIAPP; Inverted U; Supine with knees flex; Dorsal Recumbent.

Bowel sounds: Loud&Continous Normoactive 5-20 sec. 3x/min. Hypoactive <, Hyperactive >, Absent Bowel sounds: (Nsg Dx: Altered Bowel Elimination) 1. Post Operative, Anesthesia 9 Regions: 1. R&L Hypochondria 2. Epigastrium 3. R&L Lumbarkidneys 4. Umbulicussmall Intestine 5. R&L Iliac/Inguinalovaries 6. Hypogastrium/Suprapubicbladder and uterus; at back rectum. RUQ Liver & Gall bladder LLQ Sigmoid & Colon LUQ Stomach & Spleen RLQ Cecum & Appendix Epigastic Pancreas, Stomach & Bile duct

ExtremitiesInspect/Palpate GenitaliaInspect/Palpate AnusInspect/Palpate

Vital Signs:

TemperatureBalance between heat produce & heat that is lost; it is regulated by the
Hypothalamus. Factors: Produced by the activity of the muscles, hormones, metabolism; food intake, stress, climate, age, time of the day(early evening, heat is at Lowest), Progesterone(thermogenic effect; BBT early morning before rising up, 0.5 celcius for next 3 days), ovulation feels warm, before mens feels cold, utilization of Energy increase heat, more skin exposed heat loss* Nsg Dx: Alteration in body temperature. Hyperthermia/Hypothermia.

Epinephrine & NorEpinephrineStress hormones. 1. RadiationHeat loss through Electromagnetic wave. clothing. 2. ConductionHeat loss by one molecule to another. 3. ConvectionAir currence; cool air passes through body. 4. Evaporationwater converted to vapor. Eg: Remove excess Eg: Ice cap Eg: Fanning Eg: Water over skin.

HYPERTHERMIA Goal: to decrease FEVER. Nsg Intervention: depends on the stage of fever. 1. Onset/Invasion of Feverchilling; gooseflesh; pale Hot water bath; cover. 2. Stagium/Fast giving temperaturetemp. Is at its highest; flush; warm; Increase PR, RR, N/V, fan, TSB, Stripnaked. 3. Period of defervescencesweatings. Dry pts skin, make pt. comfortable. Types of Fever: 1. Remittentflactuating; dont go back to N. 2. Intermittentflactuating; go backs to N, even below N. 3. Constantflactuation is minimal. 4. Relapsingfever for 3 consecutive days, with 1-2 days without fever. If Constant antipyretic round the clock with TSB.

PEDIATRIC NURSING Puerperium6 weeks I. Physiological A. Reproductive System 1. UterusInvolution a. Uterine Contraction b. Healing c. Endometrial Regeneration Wt. Immediate after delivery: 1000g 1wk PP:500g 2wks PP:350g 6wks:80-120g After pains-1st 3 day PP *Breastfeeding *Multigravida 2. Cervix Immediate PP : 2-3 fingers/cm Shape of the cervical opening: 1 day PP1 fingerbreath below umbulicus 2 days PP2 fingerbreaths below umbulicus 3 days PP3 fingerbreaths below umbulicus 10 days PPcannot be palpated 3. Vagina Atrophy vagina mucosa/poor vaginal lubricationdecrease estrogen index *As long as episiotomy is already healed *2-3 weeks can resume coitus *3 mos. Most comfortable to become the estrogen normal *some rugae permanently flattened *myatiform caruncles with tags of tissue *remnants of the hymen 4. Lochiafrom uterus passes to vagina a. Present b. Pattern Lochia Rubra reddish3 days PP

Lochia Serosa Brownish10 days PP Lochia Alba Whitish10 days-3 wks. *Sign of Infectionif there is alteration of color No large blood clot. If large there is bleeding. Not foul smelling. 5. Hormonal Changesreturn of the menses Non breastfeeding4-6 wks rapid Breastfeeding8 wks-3 mos or longer Other Systemic changes; 1. Cardiovascular System 5-10 minPlacental separation; increase cardiac output *Physiologic bradycardia *PR 50-60 per minute *BP is N `Blood valuesN 4 wks PP 2. GITdifficulty in bowel were common 3 daysone establish normal pattern 3. Urinary System/Renal Retention with overflow *over distended bladder *urine will leak out of the bladder 50-100cc 4. Weight Immediate PPinitial weight loss *delivery of fluid(amniotic), Placenta, Blood loss *gradual weight loss Diuresisexcessive voiding 1st 24-48 hrs. Diaphoresisexcessive sweating *6wks PP20-22ibs. 5. Temperature *1st 24hrs PPslight elevation Increase Temperature; Increase RRrefer might suffering injection II. Psychosocial Aspects 3 Emotional Stage 1. Taking In1st 3 daysnot show interest in taking care of NB Exhausted; needs somebody to assist; internalize labor; experiences & Delivery. 2. Taking Holdwoman rested and ready to take responsibility *make initiative & taking care of NB 3. Letting Go3-4 wks *realize that the NB is a separate individual & not an extension of herself. Accepted new role as a MOTHER. POST PARTUM blues/ Profound Depressionthat she cannot explainmood swings Post partum Psychosis. III. Prevent Complications

A. Hemorrhage/Bleeding 1. 1st 28 days PP 2. Blood loss NSD-- < 500cc N300-500cc CS-- < 1000cc N800-1000cc 2 Types of Bleeding: a. Early1st 24 hours *Uterine atony/Uterine Relaxation *massage in circular motion *apply cold water *promote voiding *put the baby to the breasthelp uterus to contract b. Late Hemorrhageafter 24hrs *retained placental Fragments/ Tissue B. Infection 1. Perineumtenderness(Pain) Perineal Heat Perineal LightvasodilationIncrease O2; 12-18 inches from the vulva *** Promote healing 2.Endometritis Decrease Lochia; alteration in the pattern of Lochia; foul smelling ***Encourage sitting/high fowlersPromote drainage 3.Thrombophlebitis Swelling; shiny & Whitishin appearance; Phlegmasia Alba Doleus (+) Homans signdorsiflexion of the foot. AnticoagulantHeparin; does not affect the fetus; does not enter the breastmilk. *heparin antidote Protamine Sulfate Monitor bleeding/excretion 4.MastitisBreast tissues; microorganismsharbor from the nasal/oral cavities of the NB. *Reduce congestion in the breast *Reduce the Pain *Prevent milkstasis IV. Lactation and Breastfeeding BreastfeedingIncrease Metabolism; increase resistance; closer maternal & infant bonding Physio of Lactation: Separation of the placenta decrease maternal hormones increase prolactin foremilk collecting tubules (breast sinking) increase Oxytocin (PPG) contraction of smooth muscles of collecting tubules milk ejection/ let down reflex hindmilk, increase in fats, gain the baby rapidly. Increase EstrogenSupress lactation Nsg. Responsibilities: 1. Breast Caredaily bathing/ plain water; wear supportive brassierresagging 900cc/day. 2. Procedurelying/sitting position; suck including the areola; sore nipplecrack reddish; 21 watts bulb. 3. NutritionCalorie req: 3000 cal/day; malunggay & lots of fluids. 4. Drugs & MedicationsEpinephrine; anti histamine; insulin 5. Illness

V. Family planningPreventive & achieving Pregnancy a. NFPinvolves physiologic changes; fertile/non fertile period. 1. Billing/Mucus method3x a day; not reliable. 2. BBTeveryday Temp, same route; until 4 days resume coitus; elevated pregnant bec of high level Progesterone. 3. Symptothermal b. LAMLactation Amenorrhea Method 3 conditions: 1. Fully breastfeeding 2. Amenorrhea 3. 6 mos. Do not rely on Breastfeed anymore. c. SDMStandard Days Methodbeads. d. Artificial Methods: 1. IUDIntra Uterine Device Non specific inflammatory response in the endometrium. *Prevents implantation***menorrhagia heavy menstrual flow. Not advisable to adolescent & never been pregnant; possible perforation of the uterus. 2. Condoms- easy to buy; accessible. 3. Chemicals Vaginal Creams/ jelliesspermicide Apply in the wall of vagina; coitus within 2 degree Not advisable to menopausal woman 4. Hormonalinjectibles; Pills Not recommended for: *Rasl & liver dse; CV & HPN; DM; Ca; Smoking. 4 days not taking wait for another menstruation. 1day forget2 pills 2 day forget2 pills& succeding 1 pill 3 days forget2 pills & another 2 pills *HA; chest pain; leg pain; abdominal pain 5. Surgery WomanBasal tubal ligation ManVasectomy Heart DseForceps delivery Infections: German measles; Syphilis; Vaginal Infectionmoniliasis, trinomiasis a. b. c. d. e. Bleeding on 1st tri: Abortion Spontaneous maternal function; illness; hormonal imbalance ; fetal defect Threatenedavoid strenous activities; coitus Inevitable/Imminentcomplete/incomplete D&C. MissedIUFD Habitual3 consecutive times of abortion

f. Induced Abortion:

1. Therapeutic Legal- <12 wks can abort the baby in another country. Illegal-Hemorrhage/ Infection 2. Ectopic Pregnancy Outside the uterus; ovarian; cervical; abdominal Tubal Pregnancy **Previous infection affecting fallopian tube; salphingitis S/S: 1. Sudden severe knife luke pain( stabbing pain) 2. Massive bleeding 3. Accumulation of blood under umbulicus 4. Bluish discoloration of umbulicus (+) cullens sign Nsg Mgt: 1. Monitor 2. Prepare the ff: IVF set; BT set; Surgical Mgt: Salphingectomyremoval of affected fallopian tube Salphingoplastyrepair of the tube possible for another ectopic pregnancy. 2nd trimester 1. Incompetent Cervical Os Premature dilatation of the cervix18 wks of gestation Factors: 1. Hormonal imbalance 2. Structural abdomencervix 3. Repeated traumarepeated D &C. Surgical Mgt: Mc Donald Procedurepurse string suture applied around the cervix. Shirodkar Barter Sutureplace the suture deeper 2. H- Mole( hydatidiform mole) Kyawa Degeneration of the placenta; proliferation of thropoblastic villi Prone choriocarcinoma S/S: Increase HCG; excessive vomitting; rapid enlargement; absent FHT; vaginal bleeedingvaginal discharge; grapelike vesicles; clear fluid inside; HPN occurs daily <24 wks. Mgt: D&C; undergo urine examination once a month for a period of 1 year; determine HCG in urine; avoid getting pregnant. 3rd trimester: 1. Placenta Previalow implantation; painless; abdomen is soft/ bulgy Types: a. Low lying b. Partial/incomplete c. Complete Do not perform IEcauses massive bleeding; double set up OU & CS 2. Abruptio PlacentaPremature separation; painful; abdomenhard and rigid, board like. Types: a. Overtvaginal bleeding b. Concealedhidden bleeding; couvetame uterus; uterine apoplexy

c. Mixed bleedingHPN 3. PIHPregnancy Induced HPN Factors: <17y/o >35 y/o; primigravida; multiple pregnancy; poor nutrition; coexisting diseases; DM & HPN 3 Cardinal signs: 1. HPN 2. Proteinuria 3. Edema Personalized Vasoconstriction HPN Kidneys Increase Na fluid retention increase glomerular permeability proteinuria EDEMA Portal Congestion stretching of hepatic capsule Epigastric pain 2 types: 1. Pre Ecclampsia a. Mild > BP 30 mmHg 2x at 6hours intervals. Proteinuria1+/ 2+ ;5g/ day or DM **Edema of the face and finger; sudden weight gain; if the 2nd half gain more than 5 ibs a wk. b. Severe <BP 160/110 Proteinuria3+/4+; 5g of protein/day **Generalized edema; oliguria <30cc/hr; scanty urine. Placenta perfusion determination fetal distress indication for the delivery of the fetus. 2. Ecclampsia *Convulsion/ seizure; auraepigastric pain. Nsg Mgt: 1. Bed restdarkened room; L side lyng; promote diuresis. 2. Medicationanti HPN drugs; MgSO4acts as vasodilatordecrease BP; depress CNS; minimized convulsion & edema; Amt 10cc/20g order 1 amp q 4hrs; IM; divide capsule in 2 & inject on both gluteal. Monitor MgSO4 Toxicity: 1. DTRdeep tendon reflexsign of early toxicity 2. Resp functionbelow 12bpm Toxicityrespi paralysis; antidote Ca gluconate 3. Renal FunctionUO of <30cc/ hour. 4. Weigh dailyevaluate edema; before breakfast(6am) 5. Measure hourlyI/O 6. Emotional support Cureevacuate the product of conception Post partum 1st 24-48 hours possible convulsion; diminish while the pt has diuresis. 3. Diabetes Mellitus Types of DM to pregnant 1. The gestational type 1 &type 2 2. Gestational DM Diabetogenic: Increase progesterone; decrease Renal threshhold of sugar; HPL decreases sensitivity to insulin; increase Insulinase

PREGNANCY 1. PIH 2. Infection 3. Hemorrhage/ Bleeding 4. Polyhydramnios 5. Acidosis 6. Dystocia FETUS 1. Prematurity 2. Congenital anomalies4x more frequent 3. LGA Macrosomiabig/large baby >4000 g. NEWBORN 1. Hypoglycemia 2. Increase insulin level 3. Glucose level decreases 30% 4. Poor sucking/ not suck at all 5. Tremors/jittery 6. Hypocalcemia 7. Serum Ca level < decrease to 7% MULTIPLE PREGNANCYtwins 1. Monozygoticidentical twins; 1 ovum 1 sperm cell 2. Dizygoticfraternal; not the same sex; not identical; High risk factors: Age; < 17y/o >35y/o; parity- # of viable births 1st & 5th deliver is risk; interval < 3 mos from the last delivery to the next pregancy; interval of 5yrs increases. Pre pregnant weight: <70lbs, >180lbs,<410 height NB neonate 4ks-28 days Major Physiologic Adaptation: 1. Initiation of respiration 1st cry 30-60 sec. Factors: 1. Physicalchange in pressure 2. Sensorytouch, sound, temp, lighting, sound 3. Chemical changes in the blood Hypoxia, increase level of O2, 100ml lung fluid expelled passes through lung canal for expulsion of fluids to initiate respiration. 2. Changes in circulationincrease pressure in L side of heart; Foarmen Ovaleclose between atrial ductus arteriosus-close ligament arteriosus-ductus venosus-ligament venosus-umbilical vein-ligament teres. 3. Thermal adaptation temperature 37.7 c intrauterine Characteristics A. Large body surface area - Skin larger than underlying mask - Losing heat very rapidly B. Less subcutaneous fat C. Inability to shiver D. Inability to voluntary movement

E. F. -

Immature nervous system Brown fats Generate heat 100% Cold stress dangerous to NB a) Depletion of brown fats b) Increase Basal metabolic rate Increase oxygen and caloric demand Hypoxia Increase Carbon dioxide- respiratory acidosis Hypoglycemia c) Maintenance / reopening of ductus arteriosus Increase acid compounds Metabolic acidosis

Immediate Care 1. Patent airway a. Position- slight trendelenberg b. Suctioning- 5-10 seconds Avoid molonged deep suctioning Stimulate vagus nerve Bradycardia Obstruction of airway Hypoxia Pale 2. Prevent/minimize heat loss Overhead radiant warmer Droplight/goose lamp

Mechanism

Radiation- heat loss by radiation contact Convection Evaporation Conduction- warmer to cooler Cover the head of NB Warm diapers-home 3. Establish proper identification 4. Initial assessment a. Gestational age Premature term Scalp hair silky Breast bud Ear cartilage fine 3mm- diameter palpable- easily folded coarse, mm-diameter firm Full

b. Sole creases

1/3 of sole

entire sole

Male Testes- palpate, inspect Scrotum

undescended soft and round rugae furry descended abundant

APGAR SCORING: O 1 2

Heart Rate Respiratory effort Muscle tone Reflex irritability Color

Absent Absent Limp/flaccid No response Bluish/pale all over

<100min/sec Weak cry Not well flex Facial grimace w/ weak cry Body;pinkish, Extremities;bluish

>100min/sec Good cry Good flexion Good cry/sneezes Pinkish all over

1min after babys crydetermine if the baby needs CPR 5min after scorelimp(extremities remains extended) Acrocyanosis Immature circulatory system 0 3 Poor; depressed; Stat CPR 4 6 Fair condition; gurded; Close monitoring 7 10 Best possible condition Routine Measures: 1. Initial Umbilical cord dressing always count for the number of blood vessels (AVA) Clamp 1 and remaining should be only. >3 more difficult to heal; prone to infection. 2. Credes prophylaxis birth canal w/ Gonorrhea Causes permanent blindness; txSilver Nitrate 1% on lower conjunctiva, Opthalmia antibiotic tx Teramycin; Erythromycinw/ in 2hrs. time after Birth. Opthalmia Neonatorumappears 3-4 days Postpartum; Chemical irritation Chemical conjunctivitis 3. Vitamin K injectionabnormal bacterial flora in the intestine; GIT is sterile at birth. Vit K-- Dependent Blood clotting factors; Pro-thrombincauses hemorrhage. --Aquamephyton .5/ 1mg; IM vastus lateralis