Case presentation on Newborn assessment.pptx

Alhamdulillah.
here, the Case presentation on Newborn assessment with neonatal jaundice. pptx including about the disease condition like definition types, signs and symptoms, head to toe examination, nursing diagnosis, and interventions etc. Thanks to all.

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2. Presentation on Newborn assessment with physiological jaundice Presented By Rabeya Sultana Reta MSN (WHMN) 2 nd Semester, BSMMU

3. Newborn assessment A detailed and systematic whole body examination of a stabilized newborn during the early hours of life . It includes detailed history of prenatal and intranatal period and genetic history of family along with head to toe examination. 3

4. Purposes of newborn assessment To determine the normal status of different body system for healthy adaptation to extra uterine life. To detect significant medical problem for immediate management. To detect any congenital problem. To assess the need for resuscitation. To identify any health problem in early for proper treatment. Any disorder which may affect the well being of the baby. 4

5. Prerequisite for assessment Greetings and seeking permission to mother. Introduce myself to the parents and briefly explain about assessment. Prepared myself and all necessary instruments. Examine 1 hour after feeding in neutral thermal environment with presence of the mother . Adequately expose and examine gently, methodically (from top to bottom ). Opportunistic   examination   –examine those system which require a quiet child first and later that tend to disturb the child. E.g. settled baby listen heart first, in open eyes check the fundal reflexes and during crying look at the palate ! 5

6. Neonatal Jaundice Neonatal jaundice is a clinical manifestation of elevated total serum bilirubin, termed neonatal  hyper bilirubinemia , which results from bilirubin that is deposited into an infant's skin. The characteristic features of neonatal jaundice include yellowish skin, sclera, and mucous membranes . There are two types of neonatal jaundice: Physiological jaundice and Pathological jaundice. 6

7. Features of neonatal jaundice 7

8. Demographic Data Name: Baby of Mrs. N. Age: 8 days. Sex: Male. Father’s name: Md. K. Islam. Mother’s name : Mrs. N Address: B-245 , Khilgoan , C howdhury para , Dhaka. Contact no: 017 ****** 36 Bed: Cabin -1, Paying. Ward: NICU. Department: Neonatology. Hospital name: BSMMU Hospital . Date of Admission: 24/05/24 . Time: 11:15 AM. 8

9. Presenting health of neonate Yellow discoloration of palm and sole for 02 days. Exacerbation of physiological Jaundice due to IDM and dehydration . Term (37 +1 weeks), Appropriate for gestational age baby. B/O hypothyroid mother . 9

10. Gestational History Gestational age: according to weeks(37 +1 weeks ) LMP : 31-08-2023 EDD : 07-06-2024 Antenatal visit: 05 visits Antenatal medication: Zif CI, Calbo D, Esomiprazole-20mg, Montilukast-10 mg, Doxiva-200mg. Immunization history: Tetanus Toxoid 5 dose completed before pregnancy. C omplication: Polyhydramnios (based on USG, AFI- 38.4cm) at 36 wks. Of pregnancy. H/O Bronchial Asthma, controlled with oral medication. 10

11. Gestational History cont’d. Age of Mother: 32 years. Non consanguineous parent. H/O hypothyroidism which treated before pregnancy. H/O gestational diabetes mellitus which controlled with insulin. No H/O vaginal bleeding, PIH, UTI & Fever with rash. No H/O rubella, hepatitis during pregnancy VDRL was non reactive. HIV status was negative. Blood group: MBG- o +(ve) FBG- o +(ve). Fetal growth: Appropriate for gestational age. 11

12. Labor History with Baby notes Method of delivery : LSCS (H/O BA & previous C/S ) Date & time: 18/05/2024 at 12:50 PM. Placenta & membrane–Completely delivered. Sex: Male baby. Birth weight : 2380mg. Apgar score was 8 out of 10. No signs of fetal distress. No needed for any resuscitation after birth. Any abnormalities not detected. Vitamin K was given . Above information are collected from mother’s case file. 12

13. Subjective data Medical History: Yellow discoloration of body’s skin and sclera since 04 days of post natal age, then baby was admitted to the NICU at BSMMU Hospital. Baby have passed urine and meconium within 24 hours after birth. Feeding History: Exclusive breast feeding was started Immunization History: Not started yet. Family History: Father is a government service holder. Monthly income is around 60000 taka. Mother is a housewife. No any significant genetic history. 13

14. Physical examination Vital Signs: Temperature- 36.5⁰ c Pulse- 130 b/m. Respiration- 48/min. BP- 68/40 mmHg. SPO 2 : 97% with out O 2 . Anthropometry: Body length- 49 cm. Weight- 2350 gm., Birth weight-2380gm. CWL- 15.46%. OFC- 36 cm. Chest circumference- 34 cm. 14

15. General examination Color- Yellow color of skin. Jaundice- Icteric up to palm & sole. Edema- Absent. Wasting- Absent. Appearance- Normal. No any asymmetry of the face . Reflex & activity- Good. Fontanels- Open, no bulging. Mouth & oral cavity- Normal. Genitalia- Male pattern. No any Visible trauma & congenital anomaly. 15

16. Head to toe assessment Regional examination - Findings Head Shape- Normal (1/3 longer than it is wide). Fontanelle- Flat, no sunken or bulging. Eyes Both are equal in size & symmetric position. Sclera - Yellow color. Conjunctivae- No sub- conjunctival discharge. No ptosis or the presence of epicanthic folds . Positive red reflex . 16

17. Head to toe assessment Neck and clavicles length of the neck is normal, no webbing. No any neck lumps, cystic hygroma. No any clavicle fracture,   bruising , discontinuity and an abnormal position of the arm.. Nose Shape - Small and upturned No nasal flaring. Nostrils- Both are Clear & patent. No any discharge. Eyes Both are equal in size & symmetric position. Sclera - Yellow color. Conjunctivae- No sub- conjunctival discharge. No ptosis or the presence of epicanthic folds . Positive red reflex . 17

18. Head to toe assessment cont’d. Mouth & palate Lips- Normal Palate & cleft are Normal. Tongue Pink, no tongue tie. Mucous membranes Pink, Saliva Not present. No natal teeth. Ears Pinna- symmetric. No any skin tags, pits or the presence of accessory auricles. 18

19. Head to toe assessment cont’d. Face Milia present.   Chest Symmetric chest wall. Term Breast bud at both sides . Heart and Lunges normal heart rate.   No any additional sounds  . No in-drawling during inspiration. Inspiratory and  expiratory sounds at each placement. 19

20. Head to toe assessment cont’d. Abdomen Bowel sounds Present. Liver, Spleen, Kidneys are not palpable. Umbilicus-2 arteries and 1 vein present. Healthy umbilicus. Skin Yellow coloration of skin. Salmon patch present.  No Haemangiomas . No any other deviation. 20

21. Head to toe assessment cont’d. Neurological status Good crying. Good sucking reflex. Palmar grasp  reflex. Rooting reflex. Motor reflex- Symmetrical flexion . Position-Flexion of all limbs. Anus Patent. 21

22. Head to toe assessment cont’d. Genitals Scrotum- both testes are present. Size of the penis- normal (2cm). Position of the urethral meatus- central, No hypospadias or epispadias. Extremities Symmetry of the upper limbs. Brachial pulse was palpable on each upper limb. Palmar creases present. No any Polydactyl, sindyctyle. No any club foot. 22

23. Post task of assessment Tell the parent that examination is complete and dress to the baby . Share the results of the assessment with the parents. Explain if the parents have any  further  questions. Give mental support and assurance to the parents. Thank the parents for their time. Dispose of PPE appropriately and wash hands . Summaries the findings. Document the findings in baby’s file. 23

24. Laboratory findings Investigations Findings Normal values Total Serum bilirubin 12.18 mg/dl 15-18 mg/dl Direct serum bilirubin 0.87 mg/dl Up to 0.75mg/dl Blood type & Rh status O +(ve). Complete blood count (CBC) ESR 02 mm 0-10 mm/1 st hr. RBC 6.5 X10^12/L 4.5-5.5 X 10^12/L WBC 11.0 X 10^9/L 6-16 X 10^9/L Platelets 120 X 10^9/L 150-450 X 10^9/L MCHC/MCV ratio >0.25 <0.36 Neutrophil 70% 40-75 % 24

25. Nursing Diagnosis Yellow coloration of skin due to physiological  Jaundice related to dehydration and IDM. Risk for a ltered skin i ntegrity due to   Jaundice, like as skin changes, bruising. and petechea. Imbalanced nutrition   less than b ody r equirements related to poor intake and phototherapy. Risk for neonatal infection related to disease condition. 25

26. Nursing interventions with phototherapy Properly hand washing. Place the baby naked in bed. To prevent damage and dryness apply olive oil to skin . cover infant’s genitalia and eyes during phototherapy Monitor for increased temperature, it record 2 to 4 hourly. Keep baby at least 40 cm from lights. Frequent breast feeding every 2 hourly. Turn baby after each feed. Weight record- daily. Monitor urine frequency. Monitor bilirubin level every 24 hrs. 26

27. Possible side effects of phototherapy Increased insensible water loss Loose stools Skin rash Bronze baby syndrome Hyperthermia May result in hypocalcaemia. Baby has not develop any gross side effects. 27

28. Health education to the parents Educate them for signs of jaundice coming back or getting worse: baby’s skin or the whites of the eyes turns yellow. If jaundice gets worse, the yellow color will move from the eyes to the face . Then it will move down body toward the feet. Breast  Feed at least 8 to 12 times every 24 hours. Check urine output, 8 to 10 times in a day is usual. Inform that, bowel pattern may takes 2-4 weeks to normalize. 28

29. Health education cont’d. Maintain cleanliness in every   facts to the neonate. Take natural morning sun lights to the baby at home. They can help baby's body break down the bilirubin. Teach the parents about baby’s general care at home, like hair cutting, bathing etc. The baby  get better after eating for several days because the bilirubin is removed from the body with stools . 29

30. References https://geekymedics.com/newborn-baby-assessment / https:// emedicine.medscape.com/article/974786-clinical#showall https:// www.mayoclinic.org/diseases-conditions/infant-jaundice/diagnosis-treatment/drc-20373870 30

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