BORA INSTITUTE OF ALLIED HEALTH

SCIENCES HOSPITAL

SUBJECT: OBSTETRICS &

GYANECOLOGICAL NURSING

HIGH RISK NEWBORN CARE PLAN

SUBMITTED TO: SUBMITTED BY:

MRS.

CLINICAL INSTRUCTOR M. Sc. (N) 1ST YEAR

BORA INSTITUTE OF ALLIED HEALTH SCIENCES

DATE OF SUBMISSION:
 Nursing care plan – High Risk Newborn

1. Patient’s Biodata
⮚ Name B/O Renu

⮚ Age/ sex 10 Days / Male

⮚ D.O.B 2-05-2024

⮚ Father’ name Mr. Dheeraj Kumar

⮚ Address Sultanpur

⮚ Religion Hindu

⮚ Bed No. 3

⮚ ID no. 23712849376

⮚ Unit NICU

⮚ D.O.A 2-05-2024

⮚ Informant Father

⮚ Occupation of parent Teacher

⮚ Source of health care Government and Private health centers

⮚ Provisional diagnosis LBW with sepsis

⮚ Date of surgery if any ------

2. Present complaints/ chief complaints

Baby was admitted to NICU with LBW of 2 kg with risk of developing hypothermia .
3. History of illness
a. History of present illness-
Onset – 2 days
Symptoms – LBW , Hyperthermia ,Less active
Birth weight – 2000 gm
b. History of past illness-
Illnesses – Not significant
Surgeries –Not significant
Allergies – Not significant
Immunization – Not significant
Medications to be included – Not significant
4. Drug and treatment history- Information regarding various prescribed drugs, duration of
treatment with dates, response to them and unwanted effects, any current therapy today and
 preceding few days.
5. Birth history-
a. Antenatal
Any intake of drug – Mother has taken only prescribed iron and folic acid tablets in pregnancy .
Infection during pregnancy – No history of infection in pregnancy .
Antenatal visits – Mother has gone for 3 antenatal visits in nearby localty to her home .
Folic acid supplement – Mother has taken iron and folic acid supplements .
Tetanus vaccination – Mother had taken TT1 and TT2
 Alcohol – No history of alcohol intake .
Smoking – No history of smoking by mother .
Exposure to radiation – No history of radiation exposure .
Previous exposure (if any) – No history of previous exposure to the radiations .
b. Intranatal
Place & mode of delivery – The delivery was conducted in Queen Merry Hospital , KGMU ,
Lucknow .
Person conducted – Dr.Punita
Resuscitation required –Baby didn’t required Resuscitation .
c. Postnatal
Baby had cried after birth
Delayed cord clamping
Resuscitation was not needed
Breast feed not started within 1 hr of delivery .
Baby was shifted to NICU soon after the delivery for prompt management of Lowbirth weight
baby

6. Immunization status
S. No. Vaccine Normal age Given at age Remark
1 OPV-0 At birth At birth -----------
2 Hepatitis At birth At birth -----------
3 BCG At birth At birth -----------

7. Nutrition and dietary history- The b aby is on IV fluid therapy and expressed breast milk.
8. Family history & pedigree charting-
S. Name of the Age Sex Relation Occupation Any medical
No. family condition
member
1 Mr. 60 Male Grandfather Rt.army Diabetes
Hariprakash years officer Mellitus
Singh
2 Mrs. Ramita 57 Female Grandmother Housewife Hypertension
Singh years
3 Mr . Dheeraj 37 Male Father Teacher Healthy
Kumar years
4 Mrs. Reenu 35 Female Mother Housewife Healthy
Singh years
5 Master Shubh 03 Male Brother ------------- Healthy
years
Pedigree chart

60 Years 57 Years

Male

Female Patient
33 Years 35 Years 31 Years 33

2 days 03 Years

Treatment

S. Drug Dose Frequen Action Side effect and Nurses

No. (pharmacological cy /Time drug interaction Responsibility
name)
1. Vancomycin 15mg BD Antibiotics Peripheral Edema, Any unwanted
/kg Prevents Fatigue, Headache, response of drug
and treat the Diarrhea, should be
infection Flatulence, documented for
future reference .
3. Meropenem 20mg TDS Broad- Leukopenia, Monitoring
/kg spectrum Neutropenia, patients condition
antibiotics Eosinophillia, for response of
Thrombocytopenia medication
and anaemia.
Vomiting,
Diarrhoea,
Constipation
Rash
Nephrotoxicity,
hepatotoxicity.

4. Amikacin Prevents Nausea., Vomiting. Notifying the

and treat the Diarrhea., physician/surgen
infection. Headache , .Fever. for any adverse
reactions
9. Social history-
a. Play habits – Not Significant
b. Toilet training – Not Significant
c. Sleep pattern – Not Significant
d. Schooling – Not Significant
e. Behavioural disorder- Not significant

GROUP CHECKLIST FOR GENERAL ASSESSMENT OF YES NO

NEWBORN
A General appearance: Yes
▪ Posture: flexion of head and extremities,
(flexed
extremities)
extended legs and abducted thighs. Yes
▪ Activity:Active/dull Yes

▪ Body built:Thin/ well built

B Skin:
Colours: Yes
No
▪ Pale Yes
No
▪ Pink

▪ Jaundice No
Yes
▪ Cynosed
Texture:
No
▪ Smooth Yes
Yes
▪ Dry Yes
Turgor: Normal No
Yes
▪ Vernix Caseosa
Yes
Yes
▪ Lanugo

▪ Edema: Eyes, Face, Legs

 ▪ Milia

▪ Erythema Toxicum
5
DNS ▪ Strawberry Nerves/Hemangioma

▪ Harliequin Phenomena
Restores fluid electrolyte , and plasma.
Injection site reactions (pain, swelling,
▪ Mongolion Spots redness)
Hypotension Fever,Tremors.
C Head
Size:
Yes
▪ Normal No
No
▪ Microcephaly
Yes
▪ Macrocephaly
Shape:
 No
▪ Normal
Yes
▪ Abnormal No
Anterior Yes
Fontanella
▪ Palpable Yes
No
▪ Depressed No
No
▪ Bulging
Posterior Fontanella
▪ Palpable

▪ Depressed

▪ Bulging

▪ Caput Succedenum
 No
▪ Cephalhematoma
No
No
▪ Overlapping Of Sutures
No
▪ Widened Sutures And Fontanelles
No
▪ Moulding No
Yes
SCALP
▪ Abrasion/laceration

▪ Hair line-frontal

▪ Hair colour-black brown

D Eyes
Lids: edematous Yes
Iris colour: No
▪ Grey No
Yes
▪ Dark blue No

▪ Brown
No
No
▪ Fixation on
Yes
objects Sclera: No
▪ White No

▪ Blue

▪ Yellow
Subconjunctival hemorrhage
Mangoloid slanting
E Ears:
Yes
▪ Pinna in line with eyes
Yes
Yes
▪ Patent ear canal
Yes
Yes
▪ Pinna flexible
Yes
▪ Cartilage present No

▪ Skin tags

▪ Hairy ears
 ▪ Irregular shape/size
F Nose:
Yes
▪ Patent nostrils Yes No
No
▪ Nasal discharge Yes
▪ Nasal septal deviation

▪ Flaring of nares

▪ Bruised
G Mouth and external observation:
Throat:
Yes
▪ asymmetric while crying
Yes
▪ Intact lips and Yes
palate Shape: No
▪ Normal Yes

▪ Abnormal

▪ Internal observation
 Yes
▪ Uvula in midline
No
▪ Frenulum of tongue-upper present Yes
Yes
No
▪ Natal teeth
No
No
▪ Minimum salivation

▪ Micro/macro glossia( tongue)

▪ Epstein pearls

▪ Oral thrush
H Neck:
No
▪ Short Yes
▪ Thick and skin fold
I Chest:
Yes
▪ Anterior posterior and lateral diameter equal Yes
No
▪ Sternal retraction No
No
▪ Breast enlargement No
▪ Supernumerary nipples

▪ Witch milk

▪ Wide spaced nipples

J Lungs:
Yes No
▪ Symmetry on both side No
Yes No
▪ Abdominal respiration
Yes
▪ Normal breath sounds

▪ Abnormal breath sounds

▪ Irregular rate

▪ See-saw respiration
K Heart:
Yes
▪ Visible apical pulse No
No
 ▪ Cyanosis

▪ Dextrocardia
L Abdomen:
Yes
▪ Cylindrical shape Yes
No
▪ Distended Yes
( 2artery
▪ Umblical hernia + 1vein )

▪ Vessels in cord-2Artery and 1

vein 1 artery and 1 vein
▪ Femoral pulse-felt equally Yes No
No
▪ Distended veins on abdomen Yes

▪ Visible peristaltic waves

▪ Bowel sounds audible

M Female genitalia:
 No
▪ Labia majora larger than minora
No
No
▪ Labia and clitoris edematous
No
No
▪ Patent urethral meatus
No
No
▪ Patent vagina

▪ Ambiguous genitalia

▪ Pseudo menstruation

▪ Discharge present
N Male genitalia:
Yes
▪ Urethral opening at centre Yes
Yes
▪ Descended testis No
No
▪ Deep pigmented scrotum No

▪ Hypospadiasis

▪ Epispadiasis

▪ Congenital hydrocele
O Back and rectum:
Yes
▪ Spine intact Yes
No
▪ Patent and opening No
No
▪ Imperforate anus

▪ Abnormal curvature

▪ Pilonidal sinus
P Extremities:
▪ Full range of motion No
No
No
▪ Pink nail beds Yes
▪ Capillary refill 2-3 sec No
Yes
▪ Flat sole Yes
No
▪ Symmetry of extremities No
No
 No
▪ Equal muscle tone
No
▪ Polydactyly

▪ Syndactyly

▪ Dislocated hip

▪ Wide gap between 1st and 2nd toes

▪ Asymmetric length of toes

▪ Club foot
GROUP CHECKLIST FOR GENERAL ASSESSMENT OF NEWBORN YES NO

Q Neuromuscular system

Cry:
No
▪ Loud No
Yes
▪ Lusty No
Yes
▪ Weak Yes
Yes
▪ High pitched Yes
No
▪ Flexion of extremities No
Yes
▪ Extension of extremities

▪ Head lags while sitting

▪ Turn head from side to side

▪ Sign of paralysis

▪ Myoclonic jerks

▪ Head lags in all position

Assessment Of Reflexes:
Eyes:
Yes
▪ Blinking Yes

▪ Pupillary
Nose:
Yes
▪ Sneezing Yes
▪ Glabellar
Mouth and Yes
throat: Yes
▪ Sucking Yes

▪ Gagging
Yes
▪ Rooting
Yes
Extremities:
No
▪ Palmar grasp
▪ Plantar grasp

▪ Mass reflexes:

▪ Moro reflex

▪ Startle reflex

▪ Asymmetric tonic neck reflex

▪ Dancing/stepping reflex
10. Investigations

INVESTIGATION CHART

S.N.
Investigation parameters
Patient’s value
Normal valve
Remark
1
Haemoglobin
13.2 gm/dl
14-24gm/dl
Low
2
Total leucocyte count
3900cells/mm3
5000-13500/
cmm
Low
3

ABCD
E
Differential leucocyte count

Neutrophils
32%
28-38%
High
Lymphocytes
57%
55-65%
Normal
Eosinophils
02%
00-06%
Normal
Monocytes
02%
00-06%
Normal
 8 CSF EXAMINATION
□ Colour Clear

□ pH Alkaline

□ Coagulum Absent

□ Protein 87.746 mg/dl 15-45 Very high

□ Glucose 32.2 mg/dl 45-80 Low

11. Nursing Process:

Nursing Diagnosis
▪ Hyperthermia related to low birth weight as evidenced by monitoring low body temperature

▪ Fluid and electrolyte imbalance related poor feeding as evidenced by monitoring intake
output chart .
▪ Risk for infection related to low immunity .

▪ Risk for delayed growth and development

▪ Risk for death related to very low birth weight .

 Assessment Nursing Goal Planning Rationale Implementat
Diagnosis in ion
Subjective Hyperthermia To bring down To Assess the Provides base relieving
Data related to low the temperatur vital signs of line data for Vital signs
birth weight e up to the the patient . further plan of the fever . were assesses
------------- as evidenced normal care .
by monitoring 0
98.6 F and monitored
the body temperature10
temperature. To check the 10F
surgical Provides an
Objective wound of the idea about the
Data patient . signs

The body Surgical

of
temperature infection .
of the child To provide wound was
was 1010F cold sponge to assessed .
the patient .
Cold
sponge
helps
Recheck the Cold sponge
temperature of in was given .
the child after reducing the
30 min of elevated body
giving temperature .
cold sponge .

Rechecking Temperature
helps was
Administer remonitored
antipyretic in for checking
paracetamol as analysing cold sponge
per the response of response .
physician the cold
order .
sponge
therapy .

Antipyretic
drug PCM
Antipyretics intravenously
helps was given as
per the Evaluation
physician
order . Remonitor
ed
temperatur
e 99 0F
 Assessment Nursing Goal Planning Rationale Implementation Evaluation
Diagnosis
Subjective Fluid and To To monitor Provides Vital signs were Fluid and
Data the patient the fluid

---------------. and IV fluid NS

electrolyte and and DNS
level . administerd as
Administer per the
NS 0.9 % , Other physician
and DNS as prescribed order .
Objective per the medicines
physician help in
Data order .
preventing Antibiotics
The child has other
Administer amikacin ,
not taken any other complications ceftriaxone
thing by medications like infection . and other
mouth for antibiotics etc.
assessed .Bl prescribed
past 3 days as
prescribed by ood medication
from the day
the physician pressure gives through
of assessment
. monitored IV route .
.
baseline data electrolyte
electrolyte
imbalance for further level
related plan of care . maintained
poorfeeding Intake – up to
as evidenced Output some
by monitoring chart was extent .
poor Intake output monitored
breastfeeding
. monitoring
maintain the will help in
fluid the calculating
and electrolyte the amount of
patient at fluid and
normal level. content Patient was
the vital signs required. given play
of the patient material for
mind
Administering diversion .
the IV
Moniter intake fluid
output chart of maintains
 Assessment Nursing Goal Planning Rationale . Implementati
Diagnosis on
Subjective Risk for To prevent the To monitor the Provides and
Data infection chances of vital signs of idea of further Vital signs of
related to low infection in the baby. plan of care . the baby was
immunity . the baby assessed
---------------.
.
Encourage Kangaroo
mother for mother
Kangaroo Mother
Mother Care care
and helps was
Objective Breastfeeding
demonstrated
Data
in for Kangaroo
preventing mother care.
The baby Provide infection
looks weak , formula feed
idle on if prescribed and promoting
assessment . by the
weight gain .
physician in
Formula
proper amount
. Formula feed
replaces the feed
lacking given to the
Clean the amount of newborn.
baby using feed that baby
aseptic
could not get .
technique &
frequent
handling of
baby should Cleaning
be avoided ensures Baby was
prevention cleaned with
luke warm
of infection water diluted
Administer with coconut
other
oil.
medications
antibiotics etc.
as
prescribed by
the physician
.
Antibiotics
prevents
Antibiotics
and treats amikacin
infection administerd to
the baby. Evaluation
.
Risk

for
infection
reduced up
to some
extent .
 12. Prognosis

DAY PATIENT NURSING EVALUATION REMARK

PROBLEM ACTION

Newborn is LBW Administration of Some Progress

1st IV fluids
with fever improvement in 100.10F
Cold sponge and weight gain 2000
other prescribed birth wt. 2030
medications gm. Temperature
( Antibiotics and -
antipyretics ) as 101.2 0F
per the physician
order .
Newborn is having Improvement in the Progress
2nd ● Provided IV fluids.
fever , fluid and body temperature .
electrolyte
imbalance ● Administered
antipyretic &
antibiotic
medicines.
Newborn is having Improvement in the Progress
3rd ● Administered IV
chances of condition of the baby
developing fluids
infection. ● Cleaning of the
baby
● Formula feeding .

● Maintenance of
hygiene
Child feels Weakness is Progress
4th ● Provided high
weakness. reduced.
protein and
carbohydrate
rich diet to the
child
● Provided juices
tothe child.
HEALTH EDUCATION
▪ Educated the mother regarding hand hygiene and importance of clean and ventilated surrounding
for the child.
▪ Educated the mother to identify danger signs

▪ Instructed the parents for immediate medical attention if the child is having breathing difficulty.

▪ Instructed the parents about the medications to be given at home.

▪ Instructed the parents to attend follow up visits.

CONCLUSION –

In this case, the outcome is good as the newborn is having improvement in the weight gain
At the time of admission the newborn was having, fever, low weight , less active than
normal newborn but now the child is stable than earlier. The child is on intravenous fluid
and oxygen therapy. The weight of the child is also improved. The treatment of the child
is going on and the discharge is not yet planned.
References :-

• Pal Panchali. Textbook of pediatric nursing. Paras Medical Publishers, 2016 p.162-163

• Sharma Rimple. Essentials of pediatric nursing. Edition 2. Paras Medical Publishers,

Delhi: Jaypee Publication, 2017 p. 214-217

• Datta Parul. Pediatric Nursing . Edition 4. Jaypee Publication.p 170-172