Nursing Priority
- Facilitate adaptation to life outside the uterus.
- Maintain thermo-neutrality.
- Prevent complications.
- Increase parent-child closeness.
- Provide information and anticipatory guidance to parents.
- Newborns effectively adapt to life outside the uterus.
- Free of complications.
- Parent-child closeness done.
- Parents express confidence in infant care.
First Hours of Life (Marilynn E. Doenges and Mary Frances Moorhouse, 2001 in the Maternal Infant Care Plan, p. 558-566)
1. Risk for Impaired gas exchange
related to antepartum stress, excessive mucus production, and stress due to cold.
Goal:
Free from signs of respiratory distress.
Interventions :
- Measure the Apgar score in the first minute and five minutes after birth.
- Note the prenatal complications that affect the status of the placenta and / or fetal (ie., Heart or kidney disorders, hypertension due to pregnancy, or diabetes).
- Clear the airway; nasopharyngeal suction slowly, as needed. Monitor the apical pulse during suctioning.
- Dry the baby with a warm blanket, place stockings head cover, and place it in the arms of parents.
- Put the baby in a modified Trendelenburg position at an angle of 10 degrees.
Rationale :
- Help determine the need for immediate intervention (ie., Suction, oxygen). Total score from 0 to 3 showed severe asphyxia or possibility to control neurological dysfunction and / or chemically with breathing. Scores 4 to 6 aggravate the difficulty adapting to extrauterine life. Score 7 to 10 indicates no trouble adapting to extrauterine life.
- This complication can lead to chronic hypoxia and acidosis, increasing the risk of damage to the central nervous system and require repair after birth.
- Helps eliminate accumulation of fluid, facilitates breathing efforts, and help prevent aspiration. Inhalation of oropharynx cause vagal stimulation that lead to bradycardia.
- Lowering effects of cold stress (ie., An increase in oxygen demand) and is associated with hypoxia, which can further depress respiration effort and lead to acidosis when the baby force with the end product of anaerobic metabolism of lactic acid.
- Facilitate the drainage of mucus from the nasopharynx and trachea with gravity.
2. Risk for Altered body temperature
related to inability to chills, body surface area in relation to the mass, the amount of subcutaneous fat finite, non-renewable sources of fat brown and some white fat deposits, thin epidermis with pooling of blood vessels close to the skin.
Goal:
Free signs of respiratory distress and cold stress.
Interventions :
- Note the presence of fetal distress or hypoxia.
- Dry the head and the body of a newborn baby, put the stockings headgear; and wrap in a warm blanket.
- Place the newborn in warm environments or at arm's parents. Warm objects that contact the baby (ie., Scales, stethoscopes, examination table and hands).
- Note the ambient temperature. Eliminate air flow and minimize the use of air conditioning; warm up when given oxygen through a mask.
- Assess the neonate's core temperature, skin temperature secar continuous monitoring with skin testing tool appropriately.
Rationale :
- Reduce heat loss due to evaporation and conduction, humidity protects the baby from the air flow or air conditioner, and limit the stress of displacement of the uterus warm environment to a cold environment (possibly 5 F [19 ° C] lower than the temperature of intrauterine) , (Note: Due to the relatively large area of a newborn baby's head in relation to the body, the baby can experience dramatic heat loss of moisture, the head is not closed).
- Prevent heat loss through conduction, in which heat is removed from the newborn to the object or surface that is cooler than the baby. Being held tightly near the body of parents of newborns and skin contact with the skin reduce heat loss in newborns.
- A decrease in ambient temperature 2 ° C (3.6 F) sufficient to indicate neonatal oxygen consumption. Heat loss through convection occurs when the baby loses heat to the cooler air flow. Lost via radiation occurs when heat is removed from the newborn to the object or surface that is not directly related to the newborn (ie., The walls of the incubator).
- Body temperature should be maintained closer to 36,5˚C (97,6˚F). Core temperature (rectal) usually 0,5˚C (0,9˚F) higher than skin temperature, but the continuous displacement of the core to the skin occurs so that the difference between the core and skin temperature is greater, the faster removal is becoming increasingly rapid temperature cool.
3. Altered family processes
related to transition the development and / or additional family members.
Goal:
Precisely identify the baby to ensure the correct family relationships.
Interventions :
- Inform parents about the needs of the newborn soon and care given.
- Place the baby in arm mother / father, as soon as conditions allow the newborn.
- Encourage parents to caress and talk to the newborn; encourage mothers to breastfeed if desired.
Rationale :
- Eliminate the anxiety of parents with regard to their baby's condition. Help parents understand the rationale for intervention in the period from the beginning of the newborn.
- The first hour of the baby's life is the most special meaning for family interaction which can increase the initial closeness between parent and baby and the acceptance of newborns as a new family member.
- Provide an opportunity for parents and newborns start the process of recognition and proximity.