NCP The First Hour of Life

 THE FIRST HOUR OF LIFE

The primary focus at this time is the transition from intrauterine to extrauterine life, with an introduction to family members as the neonate’s condition warrants.

NEONATAL ASSESSMENT DATA BASE (Full-Term)

Circulation

Apical pulse may fluctuate from 110–180 beats per minute (bpm).
Blood pressure 60–80 mm Hg (systolic), 40–45 mm Hg (diastolic).
Heart Sounds: Located in mediastinum with point of maximal intensity just to the left of the midsternum at third or fourth intercostal space.
Murmurs common during the first few hours of life.
Umbilical cord white and gelatinous; contains two arteries and one vein.

Elimination

May void at birth
May have passed meconium at birth

Food/Fluid

Weight: 2500–4000 g (5 lb 8 oz–8 lb 13 oz)
Length: 44–55 cm (18–22 in)
Skin turgor elastic (varies according to gestational age)

Neurosensory

Muscle Tone: Hypertonic flexion of all extremities.
Awake and active, demonstrates sucking reflex for first 30 min following birth (first period of reactivity).
Asymmetrical appearance (molding, edema, hematoma).
Cry strong, lusty, medium pitch (high-pitched cry suggests genetic abnormality, hypoglycemia, or prolonged narcotic effect).

Respiration

Apgar Score: 1/5 optimal score 7–10
Rate ranges from 30–60/min; periodic pattern may be noted
Breath sounds bilateral; occasional crackles common initially
Thorax cylindrical; prominent xiphoid cartilage common

Safety

Temperature ranges from 97.7°F–99.4°F (36.5°C–37.5°C).
Some vernix present (amount and distribution dependent on gestational age).
Skin: Smooth, flexible; peeling of hands/feet may be noted; pink-tinged or ruddy color; may be mottled, display minor bruising (e.g., forceps delivery), or harlequin color changes; petechiae on head/face (may reflect increased pressure associated with delivery or nuchal cord); port-wine stains, telangiectatic nevi (eyelids, between brows, or on occiput), or mongolian spots (primarily lower back and buttocks) may be noted.
Scalp abrasion may be present (internal electrode placement).

DIAGNOSTIC STUDIES

Cord pH: Levels of 7.20–7.24 reflect a preacidotic state; lower levels indicate significant asphyxia.
Hb/Hct: Hb level of 15–20 g and Hct of 43%–61%.
Direct Coombs’ Test on Cord Blood: Determines presence of antigen-antibody complexes on red blood cell (RBC) membrane, reflecting hemolytic condition.

NURSING PRIORITIES

1. Promote effective cardiopulmonary effort.
2. Provide a thermoneutral environment, and maintain body temperature.
3. Prevent injury or complications.
4. Promote parent-infant attachment.

Full Nursing Care Plan First Hour of Life

NCP STAGE IV (First 4 Hours following delivery of the placenta)

 STAGE IV (FIRST 4 HOURS FOLLOWING DELIVERY OF THE PLACENTA)

CLIENT ASSESSMENT DATA BASE

Activity/Rest

May appear “energized” or fatigued/exhausted, sleepy

Circulation

Pulse usually slow (50–70 beats per minute [bpm], owing to vagal hypersensitivity).
Blood pressure (BP) variable; may be lower in response to analgesia/anesthesia, or elevated in response to oxytocin administration or pregnancy-induced hypertension (PIH).
Edema, if present, may be dependent (e.g., confined to lower extremities); or may include upper extremities and facies, or may be generalized (signs of PIH).
Blood loss during labor and delivery up to 400–500 ml for vaginal delivery or 600–800 ml for cesarean birth.

Ego Integrity

Emotional reactions regarding birth experience varied and changeable, e.g., excitation, disinterest (exhausted), or disappointment
May express concern or apologize for intrapartal behavior or loss of control; may express fears regarding condition of newborn and immediate neonatal care

Elimination

Hemorrhoids often present and protruding.
Bladder may be palpable over symphysis pubis, or urinary catheter may be in place.
Diuresis may occur if pressure of presenting part obstructs urinary flow, and/or intravenous (IV) fluids are administered during labor and delivery.

Flood/Fluid

May report thirst, hunger, or nausea

Neurosensory

Sensation and movement of lower extremities decreased in presence of spinal anesthesia or caudal/epidural analgesia.
Hyperreflexia may be present (suggests developing or persistent hypertension, especially in diabetic, adolescent, or primiparous client).

Pain/Discomfort

May report discomfort from various sources; e.g., afterpains, tissue trauma/episiotomy repair, bladder fullness, or feeling cold/muscle tremors with “chills”
Safety
Slight temperature elevation initially (exertion, dehydration).
Episiotomy/laceration repair intact, with tissue edges closely approximated.
Perineum free of redness, edema, ecchymosis, or discharge.
Striae may be present on abdomen, thighs, and breasts.

Sexuality

Fundus firmly contracted, midline, and located at the level of the umbilicus
Moderate amount of vaginal drainage or lochia, dark red, with only a few small clots at most (up to small plum size)
Breasts soft, with nipples erect

Social Interaction

Varied response to infant based on individual expectations, energy level, response of others, and condition of infant

Teaching/Learning
Various medications may have been administered during intrapartal period (note time and amount).
Questions or concerns voiced regarding self/infant care.

DIAGNOSTIC STUDIES

Hemoglobin/Hematocrit (Hb/Hct), Complete Blood Count (CBC), Urinalysis (UA), Other Studies: May be done as indicated by physical findings.

NURSING PRIORITIES

1. Promote family unity and bonding.
2. Prevent or control bleeding.
3. Enhance comfort.

DISCHARGE CRITERIA (FROM RECOVERY SETTING)

1. Physiologically stable
2. Ambulating/appropriate movement of lower extremities

Full Nursing Care Plan Stage 4

NCP Labor Stage I—Latent Phase

Labor Stage I—Latent Phase

The latent phase, or the first phase of stage I labor, begins with the onset of true labor and ends with the cervix dilated 4 cm. The phase averages approximately 8–10 hr, up to 20 hr for nulliparas and 3–6 hr, up to 14 hr for multiparas. It usually occurs with client at home, unless specific concerns necessitate inpatient care, e.g., spontaneous rupture of membranes (SROM), history of rapid labor, unsafe weather conditions/distance from facility.

CLIENT ASSESSMENT DATA BASE

Ego Integrity

May be excited or anxious

Pain/Discomfort

Regular contractions, increasing in frequency, duration, and severity.
Contractions are mild to moderate, 10–20 min apart, progressing to 5–7 min apart, lasting
15–20 sec, progressing to 30–40 sec.

Safety

Fetal heart tones best heard below level of umbilicus (dependent on fetal position)

Sexuality

Membranes may or may not have ruptured.
Cervix dilates from 0 to 4cm.
Fetus may be at station1 to 0 (primigravida) or from 0 to +2 cm (multigravida).
Scant vaginal discharge, may be pink or brownish mucus (“show”), or may consist of mucous plug.

NURSING PRIORITIES

1. Enhance client’s/couple’s/other involved family members’ emotional and physical preparedness for labor.
2. Promote and facilitate normal labor progress.
3. Support client’s/couple’s/involved family members’ coping abilities.
4. Prevent maternal/fetal complications.

DISCHARGE GOALS

(Inpatient care is not required in early labor, unless complications develop necessitating hospitalization.)

1. Displays only early, or no, signs of active progression of labor.
2. Demonstrates appropriate coping behaviors.
3. Understands self-care needs and signs of labor progression requiring re-evaluation.

Full Nuring Care Plan Labor Stage 1

 

NCP Genetic Counseling

Genetic Counseling

Genetic counseling is a communication process that deals with human problems associated with the occurrence or risk of a genetic disorder in a family. Counseling involves genetic screening, whereby a high-risk or general population is analyzed to detect the presence of disease, and case finding for couples at potential risk based on medical/family histories. The process can be prospective (counseling delivered to a client/couple of reproductive age before conception or before the birth of an affected child), or it can be retrospective/postnatal (counseling delivered after the birth of an affected child). In many cases, however, the need for genetic counseling first becomes apparent during the first trimester.

(Refer also to care plan [CP]: The High-Risk Pregnancy, as appropriate.)

CLIENT ASSESSMENT DATA BASE

Circulation

Hypertension
Bleeding

Ego/Integrity

May express feelings of inadequacy
Food/Fluid
Weight gain may be inappropriate for gestational stage (smaller gain may negatively affect fetus).
Maternal insulin-dependent diabetes.
Presence of eating disorders (e.g., anorexia nervosa, bulimia, or obesity).

Safety

Infection (e.g., STDs, pelvic inflammatory disease)
Presence of seizure disorder, degree/method of control
Significant exposure to radiation, toxic chemicals, or infectious teratogens (e.g., rubella, toxoplasmosis, cytomegalovirus [CMV], HIV/AIDS), postnatal infections (e.g., meningitis, encephalitis); postnatal nutritional/stimulatory deprivation
Breech presentation (especially with anencephaly)

Sexuality

History of two or more first-trimester abortions, fetal demise, or previous child with chromosomal abnormality
Birth trauma or identifiable genetically transmitted disorder
Use of ovulation stimulant such as clomiphene (Clomid) or menotropins (Pergonal)

Social Interaction

Interfamily marriage/sexual activity (consanguinity)
Guilt/blame toward self and/or partner who carries defective gene

Teaching/Learning

Positive family history/pedigree of known genetic or inherited disorders (e.g., sickle cell, cystic fibrosis, hemophilia, phenylketonuria, craniospinal defects, renal malformations, thalassemia, Huntington’s chorea) familial disorders (cancer, heart disease, diabetes, allergies), congenital abnormalities (Down syndrome, mental retardation, neural tube defects), or inborn metabolic disorder (e.g., maple syrup urine disease, Tay-Sachs disease)
Ethnic background at risk for specific disorder (e.g., black African, Mediterranean, Ashkenazi Jewish)
Maternal age >35 years
Drug usage (alcohol; over-the-counter [OTC], prescribed, or street drugs; anticonvulsant medication)

DIAGNOSTIC STUDIES

Chromosomal Analysis: Using buccal smear/serum.

Prenatal Diagnosis:

Amniocentesis (at 14–16 wk): Determines sex chromatin (rules out sex-linked disorders), karyotype (rules out chromosomal disorders), biochemical studies (rules out inborn errors of metabolism), elevation of AFP levels reflecting neural tube defects (NTDs).

Ultrasonography (using real time) Preceding/During Amniocentesis: Rules out missed abortion, visualizes term pregnancies, and helps to identify genetic/congenital problems. (Current research awaiting validation suggests a scan using a vaginal probe can be done as early as 10 weeks’ gestation to screen for Down syndrome by looking for an accumulation of fluid in the neck of the fetus.)

Serum AFP Levels (16–18 wk): Identifies NTDs; if abnormality high/low, test is repeated.

Triple-Screen (MSAFP3): Maternal serum testing at about 16 weeks’ gestation measures AFP, unconjugated estriol, and human chorionic gonadatropin (HCG) to detect problems such as open spinal or ventral wall defects, anencephaly, Down syndrome, and trisomy 18.

Amniography/Fetography: Identifies gross problems, such as major soft-tissue abnormalities, esophageal/duodenal atresia, and bone abnormalities, using special x-ray technique (may be potentially teratogenic).

Fetoscopy (considered experimental, of limited availability): Permits direct visual examination of the fetus and sampling of fetal blood/tissue samples to diagnose hereditary blood disorders (e.g., sickle cell anemia, hemophilia).

Chorionic Villi Sampling (CVS) (at 8–10 wk): May replace amniocentesis as a genetic diagnostic tool because it is performed earlier, and results are reported in 7–10 days, which is particularly beneficial if a first-trimester termination is being considered.

NURSING PRIORITIES

1. Assist client/couple/family to recognize and understand specific situation.
2. Facilitate therapeutic use of informational resources.
3. Provide ongoing emotional support.

DISCHARGE GOALS

1. Copes effectively with situation
2. Completes counseling process
3. Understands information specific to individual situation

 
Full Nursing Care Plan Genetic Counseling