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Patient
Patient
Patient
Name: Baby Boy Marquez Address: Carunuan West Rosario Launion Date of Delivery: July 7, 2011 Type of Delivery: Normal Spontaneous Delivery Case Number: 13-03-21 Attending Physician: Dr. Mercedes Socorio Pea-Contero
Newborn Care
Goals: To establish, maintain and support respirations. To provide warmth and prevent hypothermia. To ensure safety, prevent injury and infection. To identify actual or potential problems that may require immediate attention.
5. Keep the nares patent. Remove mucus and other particles that may be cause obstruction. Newborns are obligatory nose breathers until they are about 3 weeks old.
Vitamin K or Aquamephyton
The newborn has a sterile intestine at birth, hence, the newborn does not possess the intestinal bacteria that manufactures vitamin K which is necessary for the formation of clotting factors. This makes the newborn prone to bleeding. As a preventive measure, .5 (preterm) and 1 mg (full term) Vitamin K or aquamephyton is injected IM in the newborns vastus lateralis (lateral anterior thigh) muscle.
3. Avoid wetting the cord. Fold diaper below so that it does not cover the cord and does not get wet when the diaper soaks with urine. 4. 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. 5. If you notice the cord to be bleeding, apply firm pressure and check cord clamp if loose and fasten. 6. Report any unusual signs and symptoms which indicates infection.
Foul odor in the cord Presence of discharge Redness around the cord The cord remains wet and does not fall off within 7 to 10 days Newborn fever
Newborn Assessment
The APGAR SCORING SYSTEM
was developed by Dr. Virginia Apgar as a method of assessing the newborns adjustment to extrauterine life. It is taken at one minute and five minutes after birth. With depressed infants, repeat the scoring every five minutes as needed. The one minute score indicates the necessity for resuscitation. The five minute score is more reliable in predicting mortality and neurologic deficits. The most important is the heart rate, then the respiratory rate, the muscle tone, reflex irritability and color follows in decreasing order. A heart rate below 100 signifies an asphyxiated baby and a heart rate above 160 signifies distress.
Assess HEART RATE RESPIRATION MUCLE TONE REFLEX IRRITABILITY COLOR 0 Absent Absent Flaccid No response Blue all over 1 Below 100 Slow Some flexion Grimace Body pink, Extremities blue 2 Above 100 Good crying Active motion Vigorous cry Pink all over
Score: 7 10 Good adjustment, vigorous Moderately depressed infant, needs airway clearance Severely depressed infant, in need of resuscitation.