Physiological Integrity Client Explained for Students (Easy Guide)
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Original Question
Physiological Integrity Client’s five minute APGAR is 10. She is transferred to the intermittent neonatal intensive care unit (NICU) nursery. Her parent accompanies her while the mother is transferred to the recovery room. Client’s birth weight is 7 lbs 8 oz (3.40 kgs); her length is 19 in (48.26 cm). She is placed on a radiant warmer to continue with her transition into extrauterine life. The NICU nurse conducts a Ballard exam and her score equates to 40 weeks’ gestation, which correlates with her estimated date of birth (EDB). As client continues to adjust to extrauterine life under the radiant warmer, the NICU nurse completes the electronic medical record (EMR) of her physical assessment. X Present/Noted 0 Present/Not noted or observed General Appearance X Color pink X Acrocyanosis present X Flexed posture X Alert X Active Respiratory system X Airway patent X No upper airway congestion X No retractions or nasal flaring X Respiratory rate, 30 to 60 breaths/min X Lungs clear to auscultation bilaterally X Chest expansion symmetric Cardiovascular system X Heart rate strong and regular X No murmurs heard X Pulses strong and equal bilaterally Neurologic system X Moves extremities X Normotonic X Symmetric features, movement X Reflexes present X Sucking X Rooting X Moro X Grasp X Anterior fontanel soft and flat Gastrointestinal system X Abdomen soft, no distention X Cord attached and clamped X Anus apprears patent Eyes, Nose, Mouth X Eyes clear 0 Palates intact 0 Nares patent Skin X No signs of birth trauma X No lesions or abrasions Genitourinary system X Normal genitalia Other X No obvious anomalies Comments: Bilaterally cleft lip and palate noted; difficult to assess sucking reflex d/t cleft, but infant reponds (+) to rooting reflex; lung fields clear to auscultation; have not attempted to feed as of yet; glucose stable at 62 mg/dL (3.44 mmol/L); mother desires to breastfeed; will instruct mother to pump breast milk for infant.
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