REPRODUCTIVE NURSING SYSTEM

Neonatus (in 6 hours, >6 hour) Nursing Care Plan + WOC (pathophysiology +
nursing problem)

BY 10th GROUP

NURFA RAHIM HARNINGSIH (1511314007)

HAFSARI WULANDARI (1511314024)

NURSING FACULTY

ANDALAS UNIVERCITY

PADANG

2018
 CHAPTER I

INTRODUCTION

A. Background

Changes in conditions occur in neonates newborn. In the body of his mother, the fetus's
body temperature is always maintained, so was born the relationship with her mother has been
lost and the neonate must maintain their own body temperature through its metabolic activity.

Neonates are past the first life outside the womb until the age of 28 days, where there is a
very big change from life in the womb be outside the womb. At this time the organ maturation
occurs in nearly all systems. Neonates are not miniature adults, not even the miniature
children. Neonates experienced the change from life in the womb which is too dependent on
the mother into life outside the uterus completely independent.

The period of greatest change occurred during the first 24-72 hours. This transition is
almost covered all but the most important organ systems for anesthesia is circulating
respiratory system, kidneys and liver. Therefore it is necessary structuring and preparation to
commit an act against neonatal anesthesia.

B. PURPOSE

The objective is:

1. Knowing the process of change or adaptation of newborns (neonates).

2. Understanding the process of nursing care neonates.
 CHAPTER II

LITERATURE REVIEW

A. Neonates Normal Criteria

1. Normal Newborn baby physical criteria
a. Pregnant period : 37-42 weeks
b. Weight of newborn : 2500-4000 g (appropriate with pregnant periode)
c. Length of body : 44-53 cm
d. Head of diameter biparietal : 31-36 cm
e. APGAR score : 7-10
f. Without the trauma congenital of labor and the delivery
2. Normal newborn baby Neurolical criteria
a. Frog position (flexy of the upper extremity and lower extremity)
b. Moro reflex (impulse) : + and symmetry
c. Suck reflex : + in palatum molle
d. Grasp reflex : +
e. Rooting reflex : +
3. Laboratory blood of Newborn baby
a. Hb : 14-22 g/dl (amount Hb-F high, and down as add of age)
b. Ht : 43-63 %
c. Erytrocite : 4,2-6 million/mm3
d. Retikulocite : 3-7 %
e. Leucosite : 5000-30000/mm3, if there infection<5000/mm3
f. Trombocite : 150000-350000/mm3
g. Blood volume : 85 cc/Kg of weight
4. Laboratory cranial liquid of Newborn baby
a. Colour : 90-94 % xantochrome (cleaanse and yellowish)
b. Nonne/Pandy (+), and in 3rd month have to (-)
c. Protein : 200-220 mg/dl
d. Glucose : 70-80 mg/dl
e. Eritrocite : 1000-2000/LPB
 f. Leucosite : 10-20/LPB

B. Nursing care of the normal newborn

I. Assessment of newborn Baby
I.1 Goals
a. To get the basic information about newborn baby
b. Indentify transition from intrauterine to extrauterine
c. Documented the variation and reaction of individually

I.2 Principle
a. Follow the systematic approach, progressing and noninvasive be invasive,
clean to dirty principle, and head to toe.
b. Anticipation in basic history
c. No threaten
d. Use instinct that probably the something wrong
I.3 General Role
a. Keep the environment in neutral
b. ABC focus and resuscitation of heart and pulmonary
c. Symmetry assess
d. If the external abnormal present, assess the internal organ
e. Interpretation and documentation
f.
I.4 Compenent for Assessment after transition
Comprehensive nursing assessment of the newborn infant during and after
transition is a crical factors in determining the infant;s adjusment to the extrauterine
environment. During the transitional period, the nurse determines that the infant is
physiologically stable byskilled examination and assessment of the infant
thermoregulatory effort, cardiac system, and respiratory system.
1. Temperature Assess
Thermoregulation is a critical to the newborn;s survival. Axilary infant
temperature should be maintained between 97 0F(36,10C) and 99.50F (37.5 0C).
 Body temperature is assessed by recording axillary temperature attaching the
infant to a thermoprobe and recording monitor. Multiple factors affect the infant
ability to maintain body heat. First, the organ system occupies the largest area on
infant is the skin, placing the infant at high-risk for heat loss by evaporation to the
environment. Second, in newborn, the subcutaneous fat layer is thin, offering no
isulation agaist heat loss and no adequate energy source to raise body temperature.
Third factor that predisposes infant to heat loss is that infant who are chilled are
not able to produce body heat through an alternative mechanism.
2. Cardiovasculer Assess
Assessment of the cardiovasculer system after the transitional period is
directed to the infant’s ability to convert fetal circulation to postnatal circulation.
Fetal circulation during pregnancy was dependent on shunting blood flow through
the foramen ovale, and the ductus venosus. As the infant breathes on his and her
own, the inspired oxygen enters the pulmonary vasculature.
Reversing bloood flow through the fetal shunts ultimately results in heart
murmurs. Nurse have to monitor these events by carefully auscultating heart
sounds, determining heart rate, checking peripheral pulses, and observing skin
color changes indicative of improving cardiac perfusion to the extremities.
During the course of transition, the nurse would expect the infant’s heart rate
to decrease from heighs of 150 to 160 beats per minute (bpm) to a regular pattern
and rate between 130 and 140 bpm.
The nurse identifies the characteristic of peripheral pulses related to strength,
rythm, and bounding qualities; compares pulses bilaterally; and times capillary
refil (rapid refill is 3 second of less). Skin color should remain fluish or healthy
and may appear “rosy” as capillary circulation improves.
3. Respiratory Assess
Nursing asessment of the respiratory system begins with observing the
infant’s respiratory effort, listening the sounds made while the infant is breathing,
and auscultating all lung fields. Air entering the infant’s lung after delivery
competes with the fluid remaining in the alveolar spaces. Normal respiratory rates
in the newborn are 40 to 60 breaths per minute. Fluid remaining in the lung may
 cause a condition rapid more than 60 breaths per minute.Lung fields shoukd be
aucultated anteriorly and posteriorly while gently rolling the infant onto each side.
4. General Nursing Care
a. Ophthalmic Prophylaxis
Opthalmic prophylaxis is given according to institusional protocol in
oitment or drop form to prenvent gonoccocal and chlamydial infection in
neonates.
b. Vitamin K Prophylaxis
Prophylactic injection of vitamin K (0.5 to 1.0 mg phytonadiaone) is given
by intramuscular injection into the infant infant’s thigh during the first hour
of life to stimulate production of vit K by bacteria in infant’s intedtine.
c. First Bath
The first bath is given in warm water with a mild soap to remove amniotic
fluids, blood, vaginal secretions, and another residues on the skin. The nurse
should anticipate the any chilling affect from the circulating air or the bath
and take precautions to ensure that the infant is kept warm and dried quickly.
d. Positioning
The normal body assessment is flexion of both upper and lower
extremities. Asymmetrical positioning may suggest the an initial assessment
of injury or related to birth trauma.
e. Skin Color
Skin color becomes a vital part of the general nursing assessment because
the newly born infant may show sign of the jaundice or cardiovascular
instability in the first days of life.
f. Body Size
Infant size is visually approximated for head-to-toe length and abdominal
girth.
g. Reactivity
The infant reaction confirm his or her neuromuscular development. Is the
infant asleep, awake, awake and quite, or alert? Is the infant beginning to
respond to the nurse by looking and moving extremities?
 h. Physical Assessment
Weight,Measurement, and Vital Sign
The infant’s weight ingrams and length in centimeters is determined in
delivery room and during the transitional period. The frontal occipital
circumference (FOC) is measure in centimeters to around the infant for
determine head size. Vital size are taken by nurse and charted. Heart rate,
respiratory rate are determine by auscultation.temperature, blood pressure is
checked on both the thigh and the arm of infant. Systolicbloodpressure are
range from 50 to 90 mmHg, and diastolic 20 to 60 of range. Thisexamination
have to perform by nurse within the first 12hour.

I.5 APGAR system Assessment

APGR Assessment
TANDA SCORE
0 1 2
1. HR None <100x/minute >100/minute
2. Respiration None Slow, unstable Cry powerful
3. Muscle Flaccid Flexi extremity Active of
movement
4. Reflex No response Crying, weak, Cry powerful
grimase
5. Colur Bluish/pale Florid/red of All of body is
body, bluish of florid/red
extremity
The exam :
0-2 = severe Asphyxia
3-4 = moderate Asphyxia need resuscitation
5-7 = moderate Asphyxia need intermitten resucitation
8-10 = None Asphyxia, in minimal risk.
II. Nursing Diagnose
 1. Ineffective airway clearance relate with excessive mucus, unappropriate
positioning
2. Risk for imbalance body temperature relate with extremes of environmental
temperature, condition affecting temperature regulation
3. Risk for infection relate with immunosuppression , suppressed inflammatory
response, or exposure to disease outbreak.
4. Risk for Trauma relate with insufficient knowledge of savety precautions and
weakness
5. Imbalance nutrition: less than body requirements relate with insufficient
information, insuffiecient interest in food, economically disadvantage. Food
intake less thanrecomended daily allowance (RDA)
III. Intervention to the newborn Baby
1. Ineffective airway clearance
a. Clean the baby face from the amniotic fluid and the blood
b. Suction the mouth and the nasofaring, after each 5 second take a
pause for reoxigenasion.
c. Right sideways posision,
d. Use loose of cloths
e. Observation the vital sign of respiration

2. Risk for imbalance body temperature

a. Drying soon the newborn baby body
b. Take the blanket and diapers
c. Mother direct contact
d. Hot temperature around 24-25,5 0C,
e. The baby bos, out of the Room with the AC
f. Don’t bathing the newborn baby until the temperature 370C of
stabilization after 6 hour after born.vital sign observation

3. Risk for infection

a. Wash the hand befor and after give intervention
 b. Use the handscoen if contact with the body of baby
c. Give ophthalmic prophylaxis in the eyes, for chlamydial infection.
d. Check the eyes every days
e. The intervention care for the umbilical cord.
f. Give the immunitation after 24 hour.

4. Risk for Trauma

a. Assess identity of baby
b. Information added in baby identity
c. Save and protect from injury
d. Nail is savety and short
e. Don’t use the rectal thermometer
f. Don’t lay the baby alone in the open room

5. Imbalance nutrition: less than body requirements

a. Assess the strengthen of the breastfeeding
b. Assess the proper the latch on
c. Measure the body weight of the baby
d. Teach mother for protect baby from aspiration happen.
 CHAPTER III

CONCLUSION

A. Conclusion
Newborn infants (neonates) is a condition where newborn infants with gestational age 38-
40 weeks, was born through the birth canal with cephalic presentation spontaneously without
interference, strong cry, breath spontaneously and regularly, weighing between 2500-4000
grams.
In normal birth is generally not performed laboratory tests, but sometimes with a history of
pregnancy and certain conditions need to be certain laboratory tests as indicated

B. Suggestions
If in the writing of this paper are kekuarangn and error, we apologize. For that we expect
criticism and suggestions that are build so that we can make a better paper at a later date.
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