chapter 3

66

67

CHAPTER 3NURSING CARE REPORT1. 2. 3. 3.1. Case description

Mrs.Rs baby with gender male was born on Tuesday 5th May 2014 at 23:01 pm at Ulin General Hospital in Vk ward attended by midwifes. Mrs Rs baby is the second child of the couple Mr.T (30 years old) and Mrs.H (28 years old). Mr.T family address in Jl. Kelayan A Rt. 22 Banjarmasin. Education: Mr.T is junior high school and was Mrs.R last education is junior high school. Mr.T occupation is a docker and Mrs.R is a housewife (IRT). Mr.T and Mrs.R are Muslim. Mrs.R gave birth Tuesday May 5th 2014 at 23:01 pm by sectiocaesaria delivery breech presentation 32 weeks of gestation.

History of pregnancy Mrs.R,s on the assessment date Thursday May 8th 2014 containing Mrs.R when there is a history of high blood pressure (hypertension) Mrs.R ranging from 4 moths of gestation so Mrs.R more frequently checkups in the practice of midwife. During the frist trimester of fregnancy Mrs.R had a anorexia (lack of appetite) Mrs.R eat 3 time a day that was not much of only 2 spoon rice every meal, Mrs.R also did like vegetables. In the second trimester Mrs.R also lacked of appetite, Mrs.Rs ate 3 time a day but only a few 2 spoon rice and sometime ate cake and fruit. During pregnancy Mrs.R drunk milk prenagent but. Just sometimes and did to diligent. Mrs.R in Antenatal Care (ANC) on the first visit clients was weighend, height, vital signs and given iron tablet, on the second visit Mrs.R had TT immunization, on the third visit clients was weighed weight, height, mark-vital signs, examination conducted TPU Mrs.R in midwife practice. Mrs.R obstetric status is G= 1 P= 2 A= 0.

General state of Mrs.R baby are born immediate with delivery method sectiocaesaria as because he had indication syndrome eklamsia in surgey ward Ulin General Hospital with afgar score 4-6-7 Afgar score 0-3 indicates that severe asphyxia, 4-6 indicates moderate aspyhyxia, and 7 showed mild asphyxia, and 8-10 normal / healthy body. Babies born with sex is male, weight 17.50 grams, hight 43cm heart rate 138x / minute, spontaneous respiratory 40x / minute, body temperature is 36.3oC (axillary) CRT is > 2 and no birth trauma in infant. At birth the action performed on Mrs.Rs baby is cry suection of the mouth and nasal, giving gentamcyin eyes drops in both eye, and trough IM injection of vitamin K by nurses after birth the baby immediately brought to teratai ward to get treatment because the baby have indication low birth weigh.

In the family history, there are no family members Mrs.R who have a children born with low birth weight and some are giving birth in hospital rather just give birth at come assisted by a trained midwife / midwifes hometown. Genogram

Shema 3.1 genecology line generation client Note = Male = Female = Client = line generation = One home Client is second child, gender: male. Father client is child three siblings from four siblings, and mother clients is first child to from thirdsiblings. And Mrs.Rs baby is the second child of the couple Mrs.R and Mrs.T in family members no body died.Family psychosocial history on the family Mrs.R relationship is very good, Mr.R lives with her husband, children, and parents. The people are most important thing for Mrs.Rs husband, children, and parent. The attitude of the family members are very excited to welcome the birth of a baby. Mrs.R say know about little about baby care because she ever take care a she first child when frist delivery. The nurse gave nutrition and hydration in Mrs.R baby with breastfeeding / formula SGM bblr with a spuit to measure the dose of 30 ml of water each time the provision for Mrs.R baby weighing 17,50 grams through a pipette with a dose 30 cc / 3 hours at a speed of 1 ml / minute and Mrs.R baby only able to spend 10 cc / 3 hours ring rooting reflex (to the nipple) positive, and then sucking reflexes (sucking) is positive but weak, and than swallowing reflexes (swallowing) is positive but still weak, swallowing. Input of nutrients and fluid on Mrs.Rs baby still less because of breast milk Mrs.R just a little. So the Mrs.Rs baby just given formula.Result of physical examination were peformend at Mrs.Rs baby on 8th july May 2014 Mrs.Rs baby is composmentis state with vital signs: pulse 120 x / minute, respiration 48x /minute, body temperature of 36.1oC. Anthropometric examination results are: body weight 17,50 grams body length 43 cm, head circumference 31cm, chest circumference 25cm, upper circumference 8 cm. rooting refex (to the nipple) negative, sucking reflexes (sucking) weak, and swallowing reflexes (swallowing) is positive because there is no disruption in swallowing.

Examination of the head of the baby is known Mrs.Rs baby palpable soft anterior frontanelle, head circumference 33cm flat (not concave), sparse hair, forehead and scalp hair boundaries clear with black hair and sparse, picture the face is symmentrical between the left and right.

Mrs.Rs baby eyes secretion are not exeessive no sclera jaundice are anemic conjunctiva, the second position the ball left and right eyes looks symmentrical. There are no abnormalities in the eyes auch as strabismus ( crossed eyes).

Baby nasal secretions are seem excessive, no sclera no inflammation and bleeding of the nose, there is no interuption in breathing such as nostril breathing (CPH) or obstruction, normal respiration 48x /minute grabella positive reflex (baby wink at the base of the nose or between the eyes touched) baby not using a ventilator respiratory.

Baby ears looks symmentrical between left and right, do not look any inflammation or bleeding in the ear, no discharge coming out of the ear, ear cartilage rudimentary growth. Startle negative reflex (baby do not look at his ears touched with figer).

Abdomen looks symentrical between the left and right, on palpation palpable abdominal flat and soft, yet off umbilical cord looked a bit dark. Treantment is done with care to prevent humidity opens in the area and in the umbilical cord appears to be no signs of infection in the central region (umbilicus) such as temperature instability and bleeding, redness, pus and odor. No Palpable enlargement liver, bowel sounds 10x / minute

The chest Mrs.Rs baby looks symmetrical between left and right, with normal balance expansion when breathing, respiratory frequency of 48x / minute, baby did use a ventilator, no look any rib retraction. Nipples clearly palpable on both mammary papilla, areola clear, CRT circulation (blood capillary refill time) on the left back > 2 seconds, normal heart sounds no additional noise, pulse 120 x / minute

Baby extremities symmentrically between left and right, upper and lower there is no limitation of motion, positive more reflex (extension and abduction movement is the extremities when started), grasping reflex positive (finger when gripping palms affiexd to the baby). There was no trauma to in the exremities and no attached infusion in the exremities.

Baby had genitalia deformities, testes had descended into the scrotum an the rectum there is a (positive)

Slightly pale skin colour, finger nails do not look long, no cyanosis, no rash on the skin, there is no birthmark, skin turgor looked good (back in 1 second after being pinched), no edema, lanugo bit, skin looks moist and thin, fatty tissue under skin a little, the body temperature of 36,5oc. and Mrs.Rs baby was placed in the box with a thick baby clothes, and baby swaddled in a blanket. Baby was being treated in hospital, the baby was placed in an incubator he had change body temperature immaturity subcutaneous fat tissue.

Diagnostic ExaminationLaboratory result: july 7th 2014 Table 3.1 laboratory resultParameterResultRef. range CountMethode

HEMATOLOGY

HemoglobinLeokositEritrosit HematokritTrombositRCW-CV15.511.14.1645.420019.114.00 - 24.004.0 10.54.80 7.1044.00 64.00150 45011.5 14.7g/dlcolorimetric

Ribu/ulJuta/ul

Vol%Ribu/ul

%ImpedanceImpedance

Analyzer calImpedance

Analyzer cal

CV, MCH,MCHC

MCMCHMCHC109.337.234.380.0 97.027.0 32.032.0 38.0Fipg

%Analyzer calAnalyzer cal

Analyzer cal

DIFFERENTIAL COUNT

Gran%Limfosit#MID%Gran#Limfosit#MID#.545.246.38.55.005.20.950.0 70.025.0 11.04.0 11.02.50 7.0021.25 4.0%

%%

%%Impedance

ImpedanceImpedance

Impedanceimpedance

KIMIA

BLOOD GLUCOSE

Blood glucose part time86< 200Mg/dlGOD-PAP

Treatment on 5th may 2014 (at 23:01)1. Vitamin k : 1x1 Mg 2. Eyes drops gentamysin : 1x1 left and right eyes drops3. Suction oral / nasal : +4. Pasi SGM BBLR : -5. ASI : +6. Icubator : + Treatment date may 8th to may 13th 2014 Pasi SGM BBLR : 50 cc ASI : As often as possible Icubator : used when baby body temperature lowers 35.0oC

Data FocusSubjetive data:1. 2. 3. 3.1. 3.1.1. mother said that her baby milk that come out just a little bit.3.1.2. Mother said that her baby was weak in sucking reflex

Objective data :1. 2. 3. 3.1. 3.1.1. 3.1.2. 3.1.3. Mrs.Rs baby placed in the box with a thick baby clothes, and baby swaddled in a blanket. Baby being treated in hospital, the baby was placed in an incubator because Mrs.Rs baby some times temperature is down on 36.1oC.3.1.4. 3.1.5. Cord circumstances seem not out and looked a little blackish.3.1.6. At birth the baby was sucking mucus through the nasal and mouth.3.1.7. Mrs.Rs baby gestational age 32 weeks3.1.8. Baby aged 4 days.3.1.9. Subcutaneous fat look thin3.1.10. General state of compos mentis baby with AFGAR SCORE 4-6-73.1.11. Mrs.R.s baby positive more refex (extension or abduction movements in te extremities when startled), positive grasping reflex (moval time grasping fingers attached to the plam of the baby), rooting reflex(For the nipple) negative, sucking reflex (sucking) is still weak / swallowing reflex positive (swallow) but weak the swallowing reflex positive grabella (baby wink at the base nose or between the eyes being touched), startel negative reflex (baby do not look at his ears touched with a fingers).1. 2. 3. 3.1. 3.1.1. 3.1.2. 3.1.3. 3.1.4. 3.1.5. 3.1.6. 3.1.7. 3.1.8. 3.1.9. 3.1.10. Anthropometric measurements in Mrs.R.s baby body weigth is 17,50 grams body length is 43cm, head circumference 31cm, chest circumference 25cm and , upper circumference 8 cm.3.1.11. Respiratory rate wen assessment 55x/ minute.3.1.12. Mrs.Rs baby mucosa dry lips3.1.13. Mrs.Rs baby is only able to sped a PASI 10 cc / 3 hours of the recommended that 30 cc / 3hours.Palpation:1. 2. 3. 3.1. 3.1.1. 3.1.2. 3.1.3. 3.1.4. 3.1.5. 3.1.6. 3.1.7. 3.1.8. 3.1.9. 3.1.10. 3.1.11. 3.1.12. 3.1.13. 3.1.14. Baby body temperature is 36.1oC.measured use thermometer Pecussion: -Auscutation:3.1.15. At the time auscultated pulse 11x / minute.3.1.16. At the time of auscultation of bowel sounds in Mrs.Rs baby is 10x / minute.

1. 2. 3. 3.1. 3.2. Data analysis Table 3.2 Data AnalysisNo.DataProblemEtiology

1.Thursday, May 8th 2014Subjective data:-Mother said that his baby milk thatcame out just a little bit.-mother said that his baby weak. sucking reflex.Objective data:-Sucking reflexes weak rootingreflex (to the nipple)negative,reflex swallowing(swallow) positive but still weak.-Mrs.Rs baby mucosa lips looked dry.-bowel sounds are 10 x/ minute.-Mrs.Rs baby. Is only able to spend a PASI 10 cc / 3 hours from recomended is 30 cc / hours.-Vital signs: P : 110x / minute R : 55x / minute T : 36.1oC-Anthropometric data:BW: 17,50 gBL : 43cmHC : 31cmCC : 25cmUC : 8cmImbalance nutrition lessthan bodyrequirement.Weak sucking reflex, inadequate nutrition intake.

2.Thursday, May 8th 2014Subjective data: -Objective data:-Vital signs: P : 110x / minute R : 55x / minute T : 36.1oCThursday, may 8th 2014-Mrs.Rs baby placed in the with a thick baby clothes, and baby swaddled in a blanket. Baby being treated in hospital, the baby was placed in an incubator because because Mrs.Rs baby some times temperature is down on 36.1oC.

-subcutaneous fat look thin.-baby body temperature at birth is 36.1oC.-baby aged is 2 days.--Anthropometric data:BW: 17,50 gBL : 43cmHC : 31cmCC : 25cm UC : 8cmInefective thermoregulationImaturities

3.Thursday, May 8th 2014Risk factors:Subjective data :-Objective data :-General circumferences:Composmentis is with afgar score 4-6-7.-Cord circumferences: seem not out and looked a little backkish.-Baby age 2 days.-Mrs.Rs baby gestational age 32 weeks.- Hb. 15.5 g / dl- Leokosit 11.1-Vital signs: P : 110x / minute R : 55x / minute T : 36.1oC

Risk of infection

Priority Nursing Problem3.2.1. Imbalance nutrition less than body requirement related to reflex weak sucking, inadequate nutritional intake.3.2.2. Ineffective thermoregulation related to immaturities subcutaneous fat tissue.3.2.3. Risk of infection

3.3. InterventionsTable 3.3 Planning of NursingNo.Nursing diagnosisPlanning

PurposeInterventionRational

1.

2.

3.Thursday, May 8th2014.Imbalance nutrition less than body requirement related to reflex weak suck, inadequate nutritional intake.Subjective data:-Mother said that his baby milk thatcame out just a little bit.-mother said that his baby weak.sucking reflex.Objective data:-Sucking reflexes weak rootingreflex (to the nipple)negative,reflex swallowing(swallow) positive but still weak.-Mrs.Rs baby mucosa lips looked dry.-bowel sounds are 10 x/ minute.-Mrs.Rs baby. Is only able to spend a pasi 10 cc / 3 hours from recomended is 30 cc / hours.-Vital signs: P : 110x / minute R : 55x / minute T : 36.1oC-Anthropometric data:BW: 17,50 gBL : 43cmHC : 31cmCC : 25cmUC : 8cm

Thursday, May 8th 2014Ineffective thermoregulation related to immaturities subcutaneous fat tissue.Subjective data: -Objective data:-Vital signs: P : 110x / minute R : 55x / minute T : 36.1oCThursday, may 8th 2014-Mrs.Rs baby placed in the with a thick baby clothes, and baby swaddled in a blanket. Baby being treated in hospital, the baby was placed in an incubator because because Mrs.Rs baby some times temperature is down on 36.1oC.

-subcutaneous fat look thin.-baby body temperature at birth is 36.1oC.-baby aged is 2 days.-Anthropometric data:BW: 17,50 gBL : 43cmHC : 31cmCC : 25cm UC : 8cm

Thursday, May 8th 2014.Risk of infection Subjective data :-Objective data :-General circumferences:Composmentis iswith afgar score 4-6-7.-Cordcircumferences: seem not out and looked alittle backkish.-Baby age 2 days.-Mrs.Rs babygestational age 32 weeks.- Hb. 15.5 g / dl- Leokosit 11.1-Vital signs: P : 110x / minute R : 55x / minuteT : 36.5oC

Nutritional needs Mrs.Rs baby fulfilled within 3 days of treatment. With the evaluation criteria:

-weight gain occurred 2000-3000 kg

- sucking reflex (sucks) strong, rooting reflex (nipple for milk positive and swallowing reflexes (swallowing)Positive and strong.

-needs 0f food / Nutrition Mrs.RsBaby met.

-Mrs.R s baby can spend a PASI 30 cc / 3 hours.

-babie Mrs.Rs lips mucosa is not dry.

Mrs. R.s baby can maintain body temperature and it can adapted to external environment after 3 days of treatment, with evaluation Criteria:

- Mrs.Rs baby can adaptation to the environment without heavy clothing and blankets,

- vital signs with normal limits:P: 120-160x /minT: 36,5-37,5OCR: 30-60x / min

No infection in baby Mrs.Rs for 6 days of treatment, with the evaluation criteria:-general condition remained good -umbilical cord dry and not .infection- vital sings withim normal limits:T: 36.5 to 37.5ocR: 30-60x / min.1. Assess theresponse ofinfants duringfeeding (sucking, swallowing and coughing).

2. Observation addition of BW, about increase in the environmental.

3. Provide ASI / PASI (infant formula) with -+ 30 mil with slowly speed of 1 mil minute.

4. Fullfild needs to suck on Mrs.Rs baby using pipette whenfeeding time (ASI /PASI).

5. Burp baby as soon as baby is given milk finished.

1. Assess te baby,s body temperature every 2 hours

2. Place baby in box warmers / incubators

3. Keep the incubator temperature (36,5oc 37,5oc).

4. Wrap Mrs.Rs baby with a baby blanket and also cover baby head

5. Change clothes or bed linens when wet.

1. Suggest parents of baby to wash hands and used gounds before contact with baby.

2. Assess for signs of infection such as lack of temperature instability.

3. Determine gestational age at Mrs.Rs baby.

4. Wipe baby using water and soap

5. Collaboration give antibiotics intravenously if need.

6. 1. Determine the appropriate method of feeding.

2. The lack of adequate additional of WB though adequate caloric intake may indicate that use calories.

3. Important of food into the stomach too qukly can lead to rapid response back with regurgitation abdominal distension.

4. Giving oral satisfaction so the baby feels comfortable in the stomach through the sucking of charging via pipette.

5. Prevent infant choking.

1. Dectect early presence of hypothermia.

2. Maintain termor netral and prevent hypothermia infant.

3. Prevent excessive evaporation, reduce fluid invisible.

4. Reduce heat loss due to convection conduction and limiting heat loss.

5. Reduce dcrease of body temperature on infant.

1. To prevent contamination cross infection.

2. Body temperature is one of the response to infection.

3. 28-30 weeks gestation susceptible to infection because of decereased immunoglobulin (ig G) not there.

4. As a body hygiene heps prevent germs.

5. On or more agents are given depending on the nature of the pathogent and infectious disease.

3. 3.1. 3.2. 3.3. 3.4. ImplementantionTable 3.4 Implementantion of NursingNo.Day / dateTimeNoDxImplementantionEveluationsignature

1.Thursday, May 8th 2014.

09.00

09.00

10. 00

10.,10

10. 20I1. Assessing theresponse ofinfants duringfeeding (sucking, swallowing and coughing).


3. Providing ASI / PASI (infant formula) with -+ 30 mil with slowly speed of 1 mil / minute.

4. Fullfiled needs to suck on Mrs.Rs baby using pipette whenfeeding time (ASI /PASI).

5. Burping the baby as soon as baby is given milk finished.

1. Reflex sucking and swallowing is positive but weak and Mother said that his baby milk that come out just a little bit.mother said that his baby weak.

2. Mrs.R.s baby body 17,50 g body length is 43cm, head circumference 31cm, chest circumference 25cm and , upper circumference 8 cm.

3. Mrs.R.s baby only get a pasi and spend 10 cc from recomended is 30 cc / hours.

4. When using pipette the sucking reflex 5. Mrs.R.s baby positive strong.

5. Mrs.R.s baby can burping wen giving stimulation for burp.

2.Thursday, May 8th 2014.10.50

11.00

11.20

11.30

11.48

II1. Assessing te baby,s body temperature every 2 hours

2. laying baby in box warmers / incubators.

3. Keeping the incubator temperature (36,5oc 37,5oc).

4. Wrapping Mrs.Rs baby with a baby blanket and also cover baby head.

5. ChangingClothes, bed, and linens when wet.1. Mrs.R.s baby body emperature is 36.1oC.

2. Mrs.R.s baby body temperature increase 36. 4oC.

3. Incubator temperature is 36.0oC and no looked sign hypothermia on Mrs.R.s baby.

4. Body temperature Mrs.R.s baby stay awake in 36. 5oC.

5. Clothes Mrs.R.s baby dry and and no signs of Hypother mia on that baby.

3.Thursday, May 8th 2014.13.00

13.10

13.14

13. 50III1. Suggesting parents of baby to wash hands before contact with baby.

2. Assessing for signs of infection such as lack of temperature instability.

3. Determining gestational age at Mrs.Rs baby.

4. Wiping baby using water and soap.

1. Looked parent of baby wash hand and use gounds before contact with he baby.

2. No looked signs and symptom infection on Mrs.R.s baby. Body, and no icrease body temperature.T : 36. 5oC.

3. Mrs.Rs baby gestational age is 32 weeks 4 days that indicate high of risk infection.

4. Looked Mrs.Rs baby clean.

1. 2. 3. 3.1. 3.2. 3.3. 3.4. 3.5. EvaluationTable 3.5 Evaluation of NursingNo.Day/ DateTimeNo DxEvaluationSignture

1.

2. Thursday, May 8th 2014.

Thursday, May 8th 2014.

09.00

11.00

I

S : Mother said that his baby milk that come out just a little bit andmother said that his baby weak.

O : Reflex sucking and swallowing is positive but weak.

Mrs.R.s baby only get a pasi and spend 10 cc from recomended is 30 cc / hours.

Mrs.R.s baby body weignt 17,50 g. Body length is 43cm, head circumference 31cm, chest circumference 25cm and , upper circumference 8 cm.

When using pipette the sucking reflex Mrs.R.s baby positive, strong

A : The problem Imbalance nutrition less than body requirement related to reflex weak suck, inadequate nutritional intake have not been resolved.

P : Continued intervention. Assess the response of infants during feeding (sucking, swallowing and coughing).

Observation addition of BW, about increase in the environmental.

provide ASI / PASI (infant formula) with -+ 30 mil with slowly speed of 1 mil / minute.

Fullfild needs to suck on Mrs.Rs baby using pipette whenfeeding time (ASI /PASI).

Burp baby as soon as baby is given milk finished.S : -S : -O : Mrs.R.s baby body temperature is 36.1oC.

Mrs.R.s baby body temperature increase 36. 4oC.

Incubator temperature is 36.5oC and no looked sign hypothermia on Mrs.R.s baby.

Clothes Mrs.R.s baby dry and and no signs of Hypother mia on that baby.

A : Ineffective thermoregulation related to immaturity subcutaneous fat tissue has not been resolved.

P : Continued intervention Assess te baby,s body temperature every 2 hours

Place baby in box warmers incubators.

Keep the incubator temperature (36,5oc 37,5oc).

Wrap Mrs.Rs baby with a baby blanket and also cover baby head.

Change clothes, bed and linens when wet.

3.Thursday, May 8th 2014.

13.00

IIIS : -O : Looked parent of baby wash hand and use gounds before contact with he baby.

No looked signs and symptom infection on Mrs.R.s baby. Body, and no icrease body temperature. T : 36. 5oC.

Mrs.Rs baby gestational age is 32 weeks 4 days that indicate high of risk infection.

Looked Mrs.Rs baby clean.

A : Risk of infection Imaturities immune / of the possibility cross- infection does no occur and partially resolved but there is still a risk factor.

P : Continued intervention Suggest parents of baby to wash hands before contact with baby.

Assess for signs of infection such as lack of temperature instability.

Determine gestational age at Mrs.Rs baby.

Wipe baby using water and soap

Collaboration give antibiotics intravenously if need.

3.6. Progress NotesTable 3.6 Progress NotesNo.Day / DateTimeNo DxImplement ation and Evaluation MeasuresFinal EvaluationSignature

1.

2.

3.

1.

2.

3.Friday May 9th 2014.

FridayMay 9th 2014.

FridayMay 9th 2014.

Saturday May 10th 2014.



08.30

8.35

08.40

08.50

80.55

10.05

10.23

10.30

10.53

10.50

13.10

13.30

13.50

08.40

08 .42

08. 50

10. 00

10.10

11. 10

11. 12

11. 15

11.46

11.50

12.05

12.40

13.510

I

II

III

I

II

III1. Assessing theresponse ofinfants duringfeeding (sucking, swallowing and coughing).





1. Assessing te baby,s body temperature every 2 hours

2. laying baby in box warmers / incubators


4. Wrapping Mrs.Rs baby with a baby blanket and also cover baby head.

5. ChangingClothes, bed, and linens when wet.




2. Assessing theresponse ofinfants duringfeeding (sucking, swallowing and coughing).

2. Observation addition of BW, i\about increase in the environmental.

3. providing ASI / PASI (infant formula) with -+ 30 mil with slowly speed of 1 mil / minute.



1. Assessing te baby,s body temperature every 2 hours.

2. laying baby in box warmers incubators.


4. Wraping Mrs.Rs baby with a baby blanket and also cover baby head.

5. Changing clothes, bed and linens when wet.




S : Mother said that his baby milk that come out just a little bit.

Mother said that his baby still weak.

O : Mrs.R.s baby body weight still 17,50 g body length is 43cm, head circumference 31cm, chest circumference 25cm and , upper circumference 8 cm.

Mrs.R.s baby only get a pasi and spend 10 cc from recomended is 30 cc / hours.

When using pipette the sucking reflex Mrs.R.s baby positive, strong but weak when swallowing.

Mrs.R.s baby can burping after drink milk PASI and can burp.when giving stimulation A :The problem Imbalance nutrition less than body requirement related to reflex weak suck, inadequate nutritional intake have not been resolved.

P : Continued intervention.

Assess the response of infants during feeding (sucking, swallowing and coughing).

Observation addition of BW, if not an icrease in the environmental.



Burp baby as soon as baby is given milk finished.

S : -

O: Mrs.R.s baby body temperature is 36.0oC.

Mrs.R.s baby body temperature increase after laiding in incubator From 36.0oC 36.5oC

Mrs.R.s baby body looked felt comfort and no looked sign of hypother mia.

Body temperature Mrs.R.s baby stay awake in 36. 5oC. after Wrapping with a blanket and also cover baby head.

Clothes, bed, and linens Mrs.R.s baby keep dry.

A Ineffective thermoregulation related to immaturity subcutaneous fat tissue has not been resolved.

P : Continued intervention Assess te baby,s body temperature every 2 hours Place baby in box warmers incubators.

Keep the incubator temperature (36oc 37oc).



S : -

O : No looked sings and symptom infection on Mrs.Rs baby

Mrs.Rs baby gestational age is 32 weeks 5 days that stil had indicate high of risk infection.

Looked baby mrs.R.s clean and when observation no founded sings and symptom infection.

A : Risk of infection Imaturities immune / of the possibility cross- infection does no occur and has been resolved but there is still a risk factor.

P : Continued intervention



Wipe baby using water and soap.

S : Mother .said that his baby milk that come out still a little bit 10.cc - moter baby said that his baby doesnt weak

O : Mrs.R.s baby body weight icrease from 17,50 g > 17, 70 g. body length is 43cm, head circumference 31cm, chest circumference 25cm and , upper circumference 8 cm.

Mrs.R.s baby only get a pasi and can spend 15 cc from recomended is 30 cc 1 / minute.

Mrs.R.s baby can sucking strong but when swallowing still weak if used a pipette.

Mrs.R.s baby still need help for burping after drink PASI.

A : The problem Imbalance nutrition less than body requirement related to reflex weak suck, inadequate nutritional intake partially resolved

P : Continued intervention.






S : -

S : Mrs.R.s baby body temperature is 35.7oC.

Mrs.R.s baby body temperature increase after laiding in incubator From 35.7oC 36.5oC

Mrs.R.s baby body temperature still in 36.5oCand no looked sgns of hypothermia

Body temperature Mrs.R.s baby stay awake in 36. 5oC. after Wrapping with a blanket and also cover baby head.

Clothes, bed, and linens Mrs.R.s baby keep dry.

A :Ineffective thermoregulation related to immaturity subcutaneous fat tissue has not been resolved.




Change clothes, bed and linens when wet. S -

O : no looked signs and symptoms of infection and Mrs.Rs baby body temperature there no icrease still in 36. 5oC


Looked baby mrs.R.s clean and when observation no founded sings and symptom infection.






1. Sunday May 11st 201414.20

14.25

14. 30

15.00

15.20 I1. Assessing the response of infants during feeding (sucking, swallowing and coughing).




5. Burping baby as soon as baby is given milk finished.

S : Mother .said that his baby milk that come out 20.cc

- mother said that he baby had reflex of body but no too strong.

O : Mrs.R.s baby body weight is still in 17, 70 g. body length is 43cm, head circumference 31cm, chest circumference 25cm and , upper circumference 8 cm.

Mrs.R.s baby get asi 20.cc from sheMother and can spend 15.cc from recomended is 30 cc 1 / minute.

Mrs.R.s baby had sucking strong whe giving Asi used a pipette.But swallowing reflex still weak.

Mrs.R.s baby had good burp reflex but still need help for burping after drink asi milk.

A : The problem Imbalance nutrition less than body requirement related to reflex weak suck, inadequate nutritional intake partially resolved.







2.

3.

Monday May 12 nd 20141..,

2.

3.

1.

2.

3.Sunday May 11st 2014

Sunday May 11st 2014

IIMondayMay 12 nd 2014

MondayMay 12 nd 2014

ITuesdayMay 13th 2014

TuesdayMay 13th 2014

IIITuesdayMay 13th 2014

15.30

15.45

15.48

16.10

16.23

18.00

20.30

20.55

08.10

08.15

08.18

08.20

08.30

09.00

09.05

09.15

10.20

III11.00

11.50

12.05

08.10

08.15

08.40

09.10

09.15

I I10.30

10.24

10.50

11.40

12.00

13.30II

III

I

1. Assessing te baby,s body temperature every 2 hours.








1. Assessing the response of infants during feeding (sucking, swallowing and coughing).

2. Observation addition of BW, if not an icrease in the environmental.

3. providing ASI / PASI (infant formula) with -+ 30 mil with slowly speed of 1 mil / minute.



1. Assessing te baby,s body temperature every 2 hours







1. Assessing the response of infants during feeding (sucking, swallowing and coughing).

2. Observation addition of BW, if not an icrease in the environmental.




1. Assessing te baby,s body temperature every 2 hours Place baby in box warmers incubators.


3. Change clothes, bed and linens when wet.




S: -O: Mrs.R.s baby body temperature is 35.7oC.

Mrs.R.s baby body temperature increase from 35.7oC. > 36.7 oC. after laiding in incubator

Mrs.R.s baby incubator temperature keep awake in 36.5oCand no looked sgns of hypothermia on Mrs.R.s baby ,

Looked Mrs.R.s baby felt comfort after Wraping with a baby blanket and also cover baby head.

Clothes and bad Mrs.R.s baby looked dry and not make a Mrs.R.s baby felt cool

A : Ineffective thermoregulation related to immaturity subcutaneous fat tissue had not been resolved.





S : -

O : no looked signs and symptoms of infection on part of bady Mrs.Rs baby and there no icrease temperature, still in 36. 5oC


Mrs.Rs baby Skin of bady looked cleanAfter Wiping used water and soap.

A: Risk of infection Imaturities immune / of the possibility cross- infection does no occur and has been resolved but there is still a risk factor.





S : Mother .said that his baby milk that come out 25.cc

- Mother said that he baby had strong reflex of movement.

O : Mrs.R.s baby body weight is increase from 17, 70 > 17,75g. body length is 43cm, head circumference 31cm, chest circumference 25cm and , upper circumference 8 cm. Mrs.R.s baby get asi 25.cc from sheMother and increase from can spend 15.cc > 20 cc from recomended is 30 cc 1 / minute.

Mrs.R.s baby had sucking strong when giving Asi used a pipette. andswallowing reflex begin strong.

A : The problem Imbalance nutrition less than body requirement related to reflex weak suck, inadequate nutritional intake partially resolved.







S: -O: Mrs.R.s baby body temperature range is 36.1oC.

Mrs.R.s baby body temperature maintained in the range 36.5oC. after laiding in incubator

Looked Mrs.R.s baby felt comfort after Wraping with a baby blanket and also cover baby head and no looked sings of hypothermia.

Clothes and bad Mrs.R.s baby looked dry and make a Mrs.R.s baby felt warm

A : Ineffective thermoregulation related to immaturity subcutaneous fat tissue had not been resolved.




S : -

O : no looked signs and symptoms of infection on body Mrs.Rs baby and temperature maintained in the range 36. 5oC

Mrs.Rs baby gestational age is 32 weeks 8 days that still high of risk infection. Mrs.Rs baby felt comfort and skins Mrs.Rs baby looked clean after get wiping from nurse,






S : Mother .said that his baby milk that come out Full.

- Mother baby said that he baby strong reflex of movement.

O : Mrs.R.s baby body weight is still in 17, 75g. body length is 43cm, head circumference 31cm, chest circumference 25cm and , upper circumference 8 cm.

Mrs.R.s baby get asi 30.cc from sheMother and can spend 30 cc according to recomended is 30 cc 1 / minute.

Mrs.R.s baby had strong sucking reflex when giving Asi via brastmilk or pipette . andswallowing reflex is strong

A : The problem Imbalance nutrition less than body requirement related to reflex weak suck, inadequate nutritional intake partially has been resolved.

P : countinud intervention By nurse ward




S: -O: Mrs.R.s baby body temperature range is 35.2oC.

Mrs.R.s baby body temperature maintained in 36.5oC. after laiding in incubator and no looked sings of hypothermia

Looked Mrs.R.s baby felt comfort and warm after Wraping with baby blanket and also cover baby head.

Clothes and bad Mrs.R.s baby dry and make Mrs.R.s baby felt warm

A: Ineffective thermoregulation related to immaturity subcutaneous fat tissue has not been resolved.

P : Continued intervention By nurse ward

Assess te baby,s body temperature every 2 hours Place baby in box warmers incubators.



S : -

O : no looked signs and symptoms of infection on part of body Mrs.Rs baby and temperature maintained in the range 36. 5oC

Mrs.Rs baby gestational age is 32 weeks 9 days that still high of risk infection. Mrs.Rs baby felt comfort and skins Mrs.Rs baby looked clean after get wiping from nurse,A : Risk of infection Imaturities immune / of the possibility cross- pinfection does no occur and has been resolved but there is still a risk factor.

P : Continued intervention By nurse ward




28

chapter 3

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