NCP - Nursing Care Plan for Perinatal Asphyxia
Perinatal asphyxia or neonatal asphyxia is the medical condition resulting from deprivation of oxygen to a newborn infant that lasts long enough during the birth process to cause physical harm, usually to the brain. Hypoxic damage can occur to most of the infant's organs (heart, lungs, liver, gut, kidneys), but brain damage is of most concern and perhaps the least likely to quickly or completely heal. In the more pronounced cases, an infant will survive, but with damage to the brain manifested as either mental, such as developmental delay or intellectual disability, or physical, such as spasticity — in fact, spastic diplegia and the other forms of cerebral palsy almost always feature asphyxiation during the birth process as a major, if not defining, factor.
Nursing Assessment for Perinatal Asphyxia
Physical Examination
- Respiratory system
- Low Apgar scores
- Breathing shallow, irregular, tachypnea
- Snoring, breathing nostrils, retracted suplasternal / substernal, cyanosis
- Baby does not breathe / breath over 30 x
- Cardiovascular system
- Optimal pulse, rapid or irregular may be within the normal range (120-160 x / min)
- Heart rate more than 100
- Integument system
- Presence of cyanosis / pallor - indication of gravity hypoksia
- Pitting edema of the hands and feet
- Digestive system
- Weak reflexes
- Lethargy
- Small stomach capacity
- Muskoloskeletas system
- Decreased muscle tone
- Edema, weak reflexes, there are no lines on the soles of the feet most / all of the palm.
Nursing Diagnosis Nursing Care Plan for Perinatal Asphyxia
- Ineffective Breathing Pattern related to immaturity of the respiratory organs
- Risk of hypothermia related to systems that have not been mature thermoregulasi
- Imbalanced Nutrition, Less Than Body Requirements related to weak sucking reflex
