FARAJ MUHAMMAD CAREPLAN

BSCN/2020/45784

Week 2 care plan NBU

BABY’S INFORMATION

Name: Baby Agnes Samuel

DOB: 19/1/2023

DOA: 19/1/2023

IPNO; 425745

SEX: Male

Gestation: 34 weeks

Birth weight: 2400gms

Delivery: SVD

MOTHERS INFORMATION

Name: Agnes Samuel PMTCT: Negative

Age: 21yrs VDRL: Negative

Para: 1+0 Blood Group: A+

Residence: Machakos
 BABY’S HISTORY AND INFORMATION

Baby Agnes Samuel, born to a mother of age 21 years para 1+0 at gestation 34 weeks on
19/1/2023 at 1.00 am via SVD, the baby was admitted to NBU with chief complain of moderate
asphyxia and meconium aspiration, prematurity 34 weeks and low birth weight of 2300 gms on
admission, Had an APGAR score of 4/1,5/5, 6/10, blood group A+, rhesus positive, PMTCT
negative and VDRL negative. On initial examination of the newborn, no congenital abnormality
was noted, the newborn reflexes were present but weak(sucking , grasping). However the baby
had a very fast breathing and a temperature of 39 degrees celcius was a corcern. The baby’s
extremities appeared to be bluish indicating acrocyanosis. Temp – 39 RR- 88b/min Pulse –
148b/min SpO2 – 88%. Treatment of the baby is Xpen 66,205 I.U IV and Gentamycin 3mgs IV

CARE PLAN OF BABY MARY MBITHE DATE; 14/1/2022

Assessment Nursing Goals Nursing rationale implementa Evaluation

diagnosis Intervention tion
On Ineffective Ensure Sunction any To clear Sunctioning Baby
assessment breathing effective secretions the airway has been attained O2
the baby has pattern breathing from the nose for done. saturation of
fast breathing related to pattern and mouth effective 95%
and a RR of meconium breathing.
88b/min aspiration Baby to Put the baby To increase Oxygen
organs as have on O2 tissue 0.5L Baby will
Sp02 of 88% evidenced by normal therapy via perfusion administere have a
off Oxygen fast breathing oxygen nasal prongs d normal
and a RR of saturation 0.5L/min respiration
88b/min of more To have rate of
than 90% Monitor vital baseline 45b/min
within 30 signs data. Vitals
min of monitored
interventio
n
Temperature Ineffective To Monitor the To Temperatur After 30
of 39 degrees thermoregula maintain a temperature establish e monitored minutes, the
celcius tion related normal every 3 baseline every 3 baby had a
to lack of temperatur hourly data hours normal temp
subcutaneous e of 36.5- of 37
fat secondary 37.2 in the Turn off the To cool the Radiant
to next 30 radiant heater environme heater
prematurity minutes nt switched off

Poor sucking Ineffective To Position the To make it Mother has Baby has
reflex breastfeeding improve baby well easier for been taught been
related to nutrition and teach the the baby to on how to breastfeeding
Mother does immaturity and mother how breastfeed position the well and
not know how of the promote to breastfeed child during there is
to attach nervous feeding of a child with breastfeedin progressive
baby for system as the baby proper g weight gain
breastfeeding evidenced by position
a poor
sucking Give EBM To ensure EBM given
reflex 35mls/ 3 feeding via cup
hours
Bluish Ineffective To Monitor To Blood taken The baby
extremities tissue improve haemoglobin establish if to lab for will have
perfusion tissue levels theres an monitoring pinkish
related to perfusion underlying of Hb extremities
reduced after 3 Assess for condition after
cardiac hours of the capillary such as interventions
output as interventio refill anemia are done
evidenced by n
cyanosis of
the
extremities

Risk of To prevent Position on Prevents Baby has The baby

aspiration of risk of side after aspiration been exhibits no
expressed aspiration feeding of feeds positioned signs of
breastmilk well respiratory
related to cup distress
feeding and Assess
anatomic respiratory Allows for Vitals
defects of the rate and early monitored
digestive monitor vital identificati
system signs after 3 on of
hours problems
Risk of Baby to Keep the Prevent Baby kept Baby has not
hypothermia have baby warm loss of heat arm developed
related to normal and dry to have any case of
inadequate temperatur Monitor baseline Vitals hypothermia
insulating e temp data monitored
subcutaneous Prevent Plan for and within
fat loss of heat kangaroo normal
mother care

Risk for To prevent Monitor Fever, No signs of The baby has

infection the baby signs of prolonged infection not
related to from infections cry is a noted developed
inadequate getting sign of any signs of
acquired infections Change infection Strappings infection.
immunity during strapping To prevent changed
hospital everyday introductio daily
stay n of micro-
organisms
Wash hands to the baby Hands
properly washed
before To prevent before
administering infection to attending to
drugs occur the patient