NCP The Infant at 4 Weeks Following Birth

Infant ASSESSMENT DATA BASE

Review prior assessments for identified risk factors.

Activity/Rest

Infant sleep pattern well-established

Circulation

Heart rate ranges from 80–150 bpm at rest, with average rate of 120 bpm.
BP obtained by using flush technique at wrist ranges from 48–90 mm Hg, with a mean of 67 mm Hg; at ankle, 38–56 mm Hg, with a mean of 61 mm Hg.

Ego Integrity

Regards faces, especially parents’ faces, intently; may demonstrate beginning of social smile

Elimination

Urine pale or straw-colored, with output of 6–10 wet diapers per day
Abdomen soft, nondistended with bowel sounds present
Individual bowel elimination pattern established, dependent on type of feeding

Food/Fluid

Makes comfort noises during feeding, or may make small, throaty noises
Feeding generally 5–8 times per 24-hr period
Height gain 2.5 cm (1 in) monthly for first 6 mo
Weight gain of 3–5 oz/wk for first 6 mo
Drooling absent until 2–3 mo of age, when salivary glands begin to function

Neurosensory

Beginning to differentiate cry in relation to pain, discomfort, or hunger; uses cry to signal needs; quiets when picked up.
Head circumference increases 1.5 cm (1⁄2 in) monthly for first 6 mo.
Fontanels palpable and soft; posterior fontanel closes at 6 wk of age.
Tears present, with tear glands beginning to function at 2–4 wk of age.
Primitive reflexes present with strong, bilaterally equal responses.
Doll’s eye and dance reflexes fading.
Crawling movements when prone.
Lifts head momentarily from bed while on abdomen, turns head from side to side when prone.
Demonstrates tonic neck reflex when supine.
Marked head lag when pulled from lying to sitting position (back is uniformly rounded); absence of head control in sitting position.
Strong grasp reflex: Hand closes on contact with object.
Responds to environmental stimuli: Bright objects (which are best viewed 8–12 in from face), sound, and touch.

Pain/Discomfort

Continuation of pain and cramping associated with colic may be reported.

Respiration

Signs of aspiration (continued regurgitation associated with reverse peristalsis and immature or relaxed cardiac sphincter)

Safety

Axillary temperature stable between 97.7°F–98.6°F (36.5°C–37.0°C)
Perineal area clean and free of rashes

DIAGNOSTIC STUDIES

Testing dependent on individual findings, risk factors.
Urine Specific Gravity: 1.008.

NURSING PRIORITIES

1. Promote infant’s growth and development.
2. Provide information appropriate to parents’ learning needs.
3. Enhance home environment to promote infant’s safety, stimulation, and rest.

DISCHARGE GOALS

1. Various indicators of growth and development show progression WNL.
2. Parent(s) understand individual needs of infant.
3. Parent(s) demonstrate proficiency in infant care activities.
4. Plan in place to meet ongoing health monitoring/wellness needs.