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Fundamentals Theorists

Martha E. Rogers (1970, 1980, 1983, 1986, 1989)

Rogers’s Science of Unitary Human Beings

Martha Rogers first presented her theory of unitary human beings in 1970. She views the person as an irreducible whole, the whole being greater than the sum of its parts. Whole is differentiated from holistic, the latter often being used to mean only the sum of all parts. She states that humans are dynamic energy fields in continuous exchange with environmental fields, both of which are infinite. Both human and environmental fields are characterized by pattern, a universe of open systems, and four-dimensionality.  According to Rogers, unitary man

  • Is an irreducible, four-dimensional energy field, identified by pattern.
  • Manifests characteristics different from the sum of the parts.
  • Interacts continuously and creatively with the environment.
  • Behaves as a totality.
  • As a sentient being, participates creatively in change.

The key concepts Rogers uses to describe the individual and the      environment are:

  • Energy fields – are the fundamental level of humans and the environment(all that is outside a given human field).  It is dynamic, constantly exchanging energy from one to the other.
  • Openness – holds that the energy fields of humans and the environment are open systems, that is infinite, integral with one another, and in continuous process.
  • Pattern –  refers to the unique identifying behaviors, qualities, and characteristics of the energy fields that change continuously and innovatively.
  • Four-dimensionality – is a nonlinear domain without temporal or spiritual attributes. All reality is considered to be four-dimensional.

Three Principles of Homeodynamics that offers a way of perceiving how unitary human beings develop:

1. Integrality – the human and environmental fields interact mutually and simultaneously.

2. Resonancy – means the wave pattern in the fields change continuously and from lower-to higher-frequency patterns.

3. Helicy – postulates that the field changes are innovative, probabilistic, and characterized by increasing diversity of field patterns and repeating rhythmicities.

Kozier, Barbara et.al Fundamentals of Nursing 5th edition

Addison –  Wesley Publishing Company, Inc. p.50

Categories
Fundamentals Theorists

Sister Callista Roy

Roy’s Adaptation Model

Sister Callista Roy’s adaptation model, originating in 1970, is widely used by nurse educators, researchers, and practitioners. Roy focuses on the individual as a biopsychosocial adaptive system. Both the individual and the environment are sources of stimuli that require modification to promote adaptation, an ongoing purposive response. Adaptive responses contribute to health, the process of being and becoming integrated; ineffective or maladaptive responses do not.

As an  open system, an individual recieves inputs or stimuli from both the self and the environment. Roy identifies three classes of stimuli:

  1. Focal stimulus – the internal or external stimulus most immediately confronting the person and contributing to behavior
  2. Contextual stimuli – all other internal or external stimuli present
  3. Residual stimuli – beliefs, attitudes, or traits having an indeterminate effect on the person’s behavior but whose effects are no validated.

Roy’s adaptive system consists of two interrelated subsystems:

  1. The primary subsystem – is a functional or internal control process that consists of the regulator and the cognator. The regulator processes input automatically through neural-chemical-endocrine channels. The cognator processes input through cognitive pathways, such as perception, information processing, learning, judgment, and emotions. Roy views the regulator and cognator as methods of coping.
  2. The secondary subsystem – is an effector system that manifests cognator and regulator activity. It consists of four adaptive modes:
  • The physiologic mode involves the body’s basic physiologic needs and ways of adapting in regard to fluid and electrolytes, activity and rest, circulation ans oxygen, nutrition and elimination, protection, the senses, and neurologic and endocrine function.
  • The self-concept mode includes two components: the physical self, which involves sensation and body image, and the personal self, which involves self-ideal, self-consistency, and the moral-ethical self.
  • The role function mode is determined by the need for social integrity and refers to the performance of duties based on given positions within the society.
  • The interdependence mode involves one’s relations with significant others and support systems that provide help, affection, and attention.

Kozier, Barbara et.al Fundamentals of Nursing 5th edition

Addison-Wesley Publishing  Company, Inc. pp.51-52

Categories
Medical Surgical

Acquired Immunodeficiency Syndrome (HIV infection)

Acquired immunodeficiency syndrome (AIDS) is defined as the most severe form of a continuum of illnesses associated with human immunodeficiency virus (HIV) infection. HIV belongs to a group of viruses known as retroviruses. These viruses carry their genetic material in the form of ribonucleic acid (RNA) rather than deoxyribonucleic acid (DNA). Infection with HIV occurs when it enters the host CD4 (T) cell and cause this cell to replicate viral RNA and viral proteins, which in turn invade other CD4 cells.

The stage of HIV disease is based on clinical history, physical examination, laboratory evidence of immune dysfunction, signs and symptoms, and infections and malignancies. The stage of primary infection is acute and spans the time from infection to antibody development. Four categories of infected states have been denoted:

  • Primary Infection (A dramatic drop in CD4 T-cell counts from normal level between 500 and 1500 cells/mm3)
  • HIV asymptomatic (more than 500 CD4+ T lymphocytes/mm3)
  • HIV symptomatic (200-499 CD4+ T-lymphocytes/mm3)
  • AIDS (fewer than 200 CD4+ T lymphocytes/mm3)

Risk Factors

HIV is transmitted through bodily fluids by high-risk behaviors such as heterosexual intercourse with an HIV-infected partner, injection drug use, and male homosexual relations.Also at risk are people who received transfusions of blood or blood products contaminated with HIV, children born to mothers with HIV infection, breast-fed infants of HIV-infected mothers, and health care workers exposed to needle-stick injury associated with an infected patient.


Clinical Manifestations:

Symptoms are widespread and may affect any organ system. Manifestations range from mild abnormalities in immune response without overt signs and symptoms to profound immuno-suppression, life-threatening infection, malignancy, and the direct effect of HIV on body tissues.

Respiratory

  • Shortness of breath, dyspnea, cough, chest pain, and fever are associated with opportunistic infections, including Pneumocystis jiroveci pneumonia (PCP), the most common infection, and the immune reconstitution syndromes, such as Mycobacterium avium complex(MAC)/Mycobacterium avium intracellulare (MAI), which is a leading bacterial infection in AIDS patients. Legionella and CMV are other opportunistic organisms.
  • HIV-associated tuberculosis occurs early in the course of HIV infection, often preceding a diagnosis of AIDS.

Gastrointestinal

  • Loss of appetite
  • nausea and vomiting
  • Oral and esophageal candidiasis (white patches, painful swallowing, retrosternal pain, and possibly oral lesions)
  • Chronic diarrhea, possibly with devastating effects (eg, weight loss, fluid and electrolyte imbalances, perianal skin excoriation, weakness, and inability to perform activities of daily living)

Wasting Syndrome (Cachexia)

  • Multifactorial protein-energy malnutrition
  • Profound involuntary weight loss exceeding 10% of baseline body weight
  • Chronic diarrhea, chronic weakness, and documented intermittent or constant fever with no concurrent illness
  • Anorexia, diarrhea, gastrointestinal malabsorption, lack of nutrition, and for some patients a hyper metabolic state.

Neurologic

Neurologic complications involve central, peripheral, and autonomic functions

  • HIV encephalopathy (AIDS dementia complex [ADC]) occurs in two thirds of patients with AIDS. Symptoms include memory deficits, headache, lack of concentration, progressive confusion, psychomotor slowing, apathy and ataxia, and in later stages global cognitive impairments, delayed verbal responses, spastic paraparesis, hyperreflexia, psychosis, seizures, incontinence, mutism, and death.
  • HIV – related peripheral neuropathy is thought to be a demyelinating disorder; it is associated with pain and numbness in the extremities, weakness, diminished deep tendon reflexes, orthostatic hypotension, and impotence.
  • Cryptococcus neoformans, a fungal infection (fever, stiff neck, nausea and vomiting, seizures)
  • Central and peripheral neuropathies, including vascular myelopathy (spastic paraparesis, ataxia, and incontinence)
  • Progressive multifocal leukoencephalopathy (PML), a central nervous system demyelinating disorder, can occur.
  • Other neurologic disorders include Toxoplasma gondii, CMV, and Mycobacterium tuberculosis infection, with symptoms ranging from confusion to blindness, aphasia, paresis, and death.

Integumentary

  • Kaposi’s sarcoma (KS), herpes simplex and herpes zoster viruses, and various forms of dermatitis associated with painful vesicles.
  • Folliculitis, associated with dry flaking skin or atopic dermatitis (eczema or psoriasis)

Reproductive (female)

  • Persistent recurrent vaginal candidiasis may be the first sign of HIV infection
  • Ulcerative sexually transmitted diseases, such as chancroid, syphilis, and herpes, are more severe in women with HIV.
  • Veneral warts and cervical cancer/cervical intraepithelial neoplasia (CIN) may be noted.
  • Women with HIV have a higher incidince of pelvic inflammatory disease (PID) and menstrual abnormalities (amenorrhea or bleeding between periods).

Hematologic / Lymphatic

  • B-cell lymphomas, such as non-Hodgkin’s lymphoma, are the second most common AIDS-related cancer (the first is KS). These lymphomas usually  differ from those in the general population because they develop outside the lymph nodes (mostly in the brain, bone marrow, and GI tract), grow aggressively, affect multiple organs, and exhibit resistance to treatment, which may be complicated by severe hematologic toxicity.

Other: Chronic Illness and Cancers

Early diagnosis and treatment of opportunistic diseases and antiviral therapy have brought HIV infection into the chronic illness category. Additional clinical manifestations follow:

  • Fatigue, headache, profuse night sweats, unexplained weight loss, dry cough, shortness of breath, extreme weakness, diarrhea, decreased endurance, edema, blindness, swallowing difficulties, and possible neurologic involvement resulting in dementia, hemiplegia, spastic paraparesis, painful neuropathies, proximal and distal muscle weakness, and persistent lymphadenopathy.
  • Higher than usual incidence of cancer, including KS, B-cell lymphomas and carcinomas of cervix, skin, stomach, pancreas, rectum, and bladder.
  • Depressive symptoms from multiple causes, including preexisting mental illness, neuropsychiatric disturbances, and psychosocial factors
  • Irrational guilt, loss of self-esteem, helplessness,worthlessness, and suicidal ideation.

Assessment and Diagnostic Methods

Confirmation of HIV antibodies is done using enzyme immunoassay(EIA; formerly enzyme-linked immunosorbent assay [ELISA]), Western blot assay, and viral load tests such as target amplification methods.

Medical Management

Currently there is no cure for HIV or AIDS, although researchers continue to work on developing a vaccine. Treatment decisions for an individual patient are based on three factors: HIV RNA (viral load), CD4 T-cell counts, and the clinical condition of the patient (severity of symptoms and patient’s commitment to participate in lifelong therapy). The goals of treatment are maximal  and durable suppression of viral load, restoration and/or preservation of immunologic function, improvement of quality of life, and reduction of HIV-related morbidity and mortality. To determine and evaluate the treatment plan, viral load testing is recommended at diagnosis and then 3 to 4 months thereafter in the untreated person. CD4+ T-cell counts should be measured at diagnosis and generally every 3 to 6 months thereafter.

Combination therapy is defined as a regimen containing at least two antiretroviral agents; highly active antiretroviral therapy (HAART) includes at least one nucleoside reverse transcriptase inhibitor plus various other drug combination. As new medications are developed, the number of combinations continues to increase. High cost of medications, difficulties with adherence to the regimen, drug resistance, and drug toxicities present problems in drug therapy. Intermittent therapy is under investigation as an alternative regimen.

Pharmacologic Therapy

Antiretroviral Therapy (ART)

  • Nucleoside/nucleotide reverse transcriptase inhibitors (NRTI)
  • Non-nucleoside reverse transcriptase inhibitors (NNRTI)
  • Protease inhibitors (PI)
  • Fusion inhibitors (FI)

Drug Resistance Testing

Helps determine which antiretroviral agents to eliminate from the antiretroviral regimen (rather than which agents should be used)

Treatment Interruption and Reinstitution

Depending on the patient and CD4 cell count, ART may be temporarily discontinued when immune competence recurs and stabilizes (eg, sustained CD4 count between 500 and 800 cells/mm3). Then, when CD4 count fall between 350 and 400 cells/mm3, ART should restart.

Medications for HIV-related Infections

  • PCP: trimethoprim-sulfamethoxazole (TMP-SMZ) and antibacterial agents, such as dapsone, alternatively, pentamidine, an antiprotozoal agent
  • MAC: treatment for MAC infections involves use of either clarithromycin (Biaxin) or azithromycin (Zithromax). The combinaiton of azithromycun with rifabutin (Mycobutin) is more effective but costly, with more adverse effects and interactions.
  • Cryptococcal meningitis:  intravenous amphotericin B with or without antifungal agents, such as fluconazole (Diflucan) or flucytosine (Ancobon).
  • CMV retinitis: ganciclovir, foscarnet, or cidofovir
  • Encephalitis: pyrimethamine (Daraprim) and sulfadiazine or clindamycin (Cleocin)
  • Candidiasis: clotrimazole (Mycelex), ketoconazole, or fluconazole

Anticancer Agents

  • KS: alpha-interferon, surgical excision of lesions, liquid nitrogen to lesions, vinblastine injected into intraoral lesions, interferon;  chemotherapy with doxorubicin (Adriamycin), bleomycin, and vincristine (ABV); radiation
  • Lymphomas: limited successful treatment; chemotherapy and radiation therapy may be used

Immunomodulators

  • Alpha-interferon
  • Other substances under evaluation (interleukin-2, interleukin-12, and other cytokines and lymphokines)

Antidepressants

Psychotherapy is integrated with pharmacology (imipramine [Tofranil]), desipramine [Norpramin], fluoxetine [Prozac], methylphenidate [Ritalin]; electroconvulsive therapy if depression is severe).

Antidiarrheal Agents and Appetite Stimulants

Octreotide acetate (Sandostatin) is given to treat diarrhea and megestrol acetate (Megace) or dronabinol (Marinol) to stimulate appetite.

Reference:

Brunner & Suddath’s

Textbook of Medical-Surgical Nursing 11th edition

Lippincott Williams & Wilkins pp.1-7

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Case Study

OB Care Study

I. INTRODUCTION

Pregnancy is one of the miracles of life. It is so amazing how a creature emerges from another creature, quite similar in genetic make-up but a totally different individual with a unique personality and a distinct characteristic. A creature undergoes pain in giving life to another creature which only shows that each of them is created with the great love felt for one another. Truly, the Creator made this life perfect, a bit of pain and suffering, but with  a basket  full of love.

Childbearing is a no shaggy dog story. It is one of the complex processes that all women who wants to have a child should undergo and it encompasses a lot of problems and complications. It has different stages, phases, and  periods, each of which has a whole new experience to offer to each conceiving mother.

The pregnancy is divided into 3 periods – Anterpartum, Intrapartum, and Postpartum period. Antepartum is the period of time from the fertilization up to the time the labor begins. Controversies over the beginning of pregnancy usually occur in the abortion debate, it is not primarily a scientific  issue since knowledge of human reproduction and development has long been refined, it is rather a linguistic and definitional question. Antepartum is also the time where  a lot of physiological changes takes place in a conceiving woman, these changes should be understood in order to have a optimum condition and the most favorable outcome (www.nursingcrib.com).

Intrapartum, the period of actual birthing process is divided into 4 stages. The 1st stage (Dilatation), 2nd  stage (Delivery), 3rd stage (Placental and 4th stage (Recovery). At this period, management and delivery of care to the women in labor is very important since it is at this stage the greatest pain of pregnancy is felt . (www.nursingcrib.com)

Postpartum period refers to the 6-week period after childbirth. This is the time of maternal changes that are both retrogressive (involution of the uterus and vagina) and progressive (production of milk for lactation, restoration of normal menstruation cycle, and beginning of the parenting role. (www.nursingcrib.com)

The students are required to provide nursing interventions to their assigned patients and compare those interventions to what they learned in school and in textbooks in order for them to understand real situations and able to compare the positive and negative corners of these type of actual situations.

II. PATIENT’S PROFILE

  • Name of Patient
  • Age
  • Address
  • Birthplace
  • Religion
  • Educational Attainment
  • Occupation
  • Name of Husband/Occupation
  • Menarche
  • Last Menstrual Period
  • GPTPAL
  • Immunization
  • Prenatal Records
  • Date of Admission
  • Time of Admission
  • Time of Delivery
  • Chief Complaints
  • Vital signs upon admission
  • Physician

III. STAGES OF LABOR

Labor is considered “normal” when the woman is at or neat term, no complications exists, a single fetus presents by vertex, and labor is completed within 24 hours. (Bobak L&M Jensen, 1993). The course of labor has 4 stages.

The first stage of labor or the stage of cervical dilatation lasts from the onset of regular contractions to effacement full dilation of cervix. This stage average about 13 hrs. for nullipara and about 7.5 hrs. for a multipara. In this stage there are 3 phases.  The first phase or the latent phase has a cervix that dilates from 0-3 cm and contractions usually every  5-20 minutes lasting 20-40 seconds and of mild intensity. These contractions will progress to about every 5 minutes and established a regular pattern.

In the active phase, the cervix dilates from 4-7 cm, the contractions are usually every 2-5 minutes lasting 30-50 sec and intensity is mild to moderate. The last phase is the transitional phase. This time the cervix dilates from 8-10 com with contractions every 2-3 minutes that lasts 50-60 seconds. Some contractions may last up to 90 seconds. The intensity is moderate to strong.

The second stage is the the Stage of Expulsion.  This stage begins with complete cervical dilation and ends with the birth of the baby. This period may last from 1-4 hours on nullipara and 20-45 minutes on the multiparas.

The third stage or the Placental Stage begins with the delivery of the baby and ends with delivery of the placenta. This may last from a few minutes – 30 minutes (include signs of placental separation).

The last stage or the Recovery Stage will lasts from the delivery of the placenta until the postpartum condition of the woman has stabilized (usually 1 hour after delivery)

PHYSIOLOGIC CHANGES DURING PREGNANCY

Anatomy of the Female Reproductive Organ

The female reproductive organ is composed of fallopian tubes, ovaries, uterus, cervix and vagina.

Uterus

Main function:

  • Accept fertilized ovum which becomes implanted into the endometrium and derives nourishment from blood vessels which develop exclusively for this purpose. The fertilized ovum becomes an embryo, develops into a fetus and gestates until childbirth.

Cervix

Main Function:

  • During pregnancy, the cervix lengthens serving as a barrier. When labor begins, the cervix begins to shorten, dilating to an opening of about 10 centimeters (about 4 inches) to allow the fetus to pass through. The cervix becomes thin and merges with the uterus (effacement) during the first stage of labor.

Vagina

Main Function

  • During childbirth, the vagina provides the channel to deliver the baby from the uterus to its independent life outside the body of the mother. The vagina  is often referred to as the birth canal. It is remarkably elastic and stretches to many times its normal diameter during vaginal birth.

Fallopian Tubes

Main Function

  • Plays an integral role in ovulation and conception. Without the fallopian tube, the egg cannot become fertilized and an embryo cannot reach the uterus for implantation.

Ovaries

Main Function

  • Each ovary takes turns releasing eggs every month; however if there was a case where one ovary was absent or dysfunctional then the other ovary would continue providing eggs to be released.

IV. IDEAL NURSING INTERVENTIONS

First Stage of Labor – Dilation of Cervix

Nursing Diagnosis:

Altered Nutrition: less than body requirements related to food restrictions during labor

Intervention:

  • Discuss eating habits, including food preferences, intolerance / aversions to appeal to client likes.
  • Emphasizes the importance of well-balanced diet, nutritious  intake

Rationale:

  • This will help patient determine the foods that she needs and the foods that are not allowed for to her to take.
  • Having a well-balanced diet will not make the patient malnourished because she has enough nutrients that her body needs.  This will also prevent her from becoming overweight.

Evaluation

  • Measure the patients I & O
  • Check the patient’s skin for good skin turgor
  • Demonstrate behaviors to monitor and correct deficit as indicated

Anxiety related to concern for self and the fetus

Intervention:

  • Promote client control where possible and help client identify and accept those things over which control is not possible
  • Provide information in verbal and written form. Speak in simple sentences and concrete terms.
  • Stay with the client or make arrangements for someone to be there for the client.

Rationale:

  • This will give the client the idea that she is still in control of the situation
  • This will help in alleviating the patient’s anxiety because she will be wondering about what will happen during the procedure.
  • Sense of abandonment can promote fear.

Evaluation:

  • Acknowledge and discuss fears, recognizing healthy and unhealthy fears.
  • Patient understands the procedure that she will be undertaking.
  • Display appropriate range of feeling and lessened fear.

Latent Phase

Nursing Interventions:

  • Maintaining Nutrition and Hydration – provide clear liquids, evaluate urine for ketones and glucose; administer intravenous fluids as indicated.
  • Relieve Anxiety – establish a relationship with woman/couple; explained the procedure to the patient, inform woman/couple of maternal status and fetal status and labor progress.
  • Controlling Pain – encourage ambulation as tolerated if membranes are not ruptures and the presenting part is engaged;  encourage diversional activities; encourage relaxation technique like warm shower; and provide  comfort measures by giving back rubs or massage.

Active/Transitional Phase

Nursing Interventions:

  • Relieving Anxiety – monitor maternal vital signs and FHR and keep woman inform of the status; provide encouragement and support; and involve support person in woman’s care.
  • Minimizing Pain – encourage position changes for comfort; assist woman with breathing and relaxation techniques; provide massage; administer prescribed analgesia as needed; observed for drug reaction; and maintain IV fluids
  • Encourage Bladder emptying – encourage woman to void every 2 hours at least 100ml
  • Strengthening Coping with Active Labor and transition – assist woman with breathing and relaxation techniques; encourage positive attitude; and provide comfort measures
  • Preventing Intrauterine Infection –  provide perineal care and change pads and linens when wet or soiled.
  • Maintaining Mobility –  encourage position change in bed as indicated; encourage ambulation and assist with back rubs, leg massage, and leg exercise while in bed
  • Encourage Effective Breathing Techniques – assist the woman in proper breathing and relaxation techniques as needed to maintain control

Evaluation:

  • Verbalized positive statements about self and fetus
  • Report pain decreased from comfort strategies and medical interventions
  • Bladder remain undistented and the woman voids
  • Absence of fever and signs of infection
  • Use breathing techniques during contractions

Second Stage of Labor – Fetal Expulsion

Nursing Diagnosis

Fear/Anxiety related to impending delivery

Interventions:

  • Give “permission” to express feelings
  • Provide opportunity for questions and answer appropriately

Rationale:

  • This will help ease the anxiety and fear of the patient
  • Enhances sense of trust and client-nurse relationship

Evaluation:

  • Display appropriate range of feelings and lessened fear
  • Verbalized accurate knowledge sense of safety related to current situation

Risk for Infection related to episiotomy and/or tissue

Interventions:

  • Cleanse incisions/inserting sites daily
  • Emphasize necessity of taking antibiotics as directed
  • Advise the patient to practice self perineal care

Rationale:

  • This will help avoid contaminating the wound.
  • The antibiotics will help the patient’s immune defense kill off the bacteria that is already affecting the wound or incision.
  • Basic perineal care will remove the dirt that are lodging in the patients perineal area that may cause infections.

Evaluation:

  • Identify interventions to prevent/reduce risk of infection
  • Demonstrate techniques, lifestyles changes to promote safe environment
  • Can follow taking the prescribed medications without the guidance of then care provider

Third Stage of Labor – Placental Expulsion

Nursing Diagnosis

Impaired Tissue Integrity related to placental separation

Interventions:

  • Check to see that the placenta and membranes are complete.
  • Evaluate the placenta for size, shape and cord site implantation
  • Evaluate vaginal bleeding

Rationale:

  • If there are parts of the placenta that will be left behind then it would cause bleeding
  • This is to assess the placenta for recording and to see if there is a full expulsion of the placenta
  • make sure that there are no fragments of the placenta that is being left behind to avoid postpartum bleeding.

Evaluation:

  • Full placenta will not cause postpartum hemorrhage
  • Patient will help in the full delivery of the placenta

NEWBORN CARE

Nursing Intervention:

  1. Weight infant and record weight.
  2. Take temperature through rectal and provide warm environment
  3. Take blood pressure

Rationale:

  1. Infant may lose 5%-10% of birth weight because of minimal intake of nutrients and fluid and loss of excess fluids.
  2. Use rectal thermometer predisposes to irritation of rectal mucosa
  3. Hypotension maybe present and require remedial action

Bathing Technique

  1. Use cotton balls or soft  disposable washcloths to wipe eyes, face and outer ears
  2. Use hypoallergenic soap
  3. Wash infant’s head gently.
  4. Tilt head back to cleanse the neck
  5. Bathe torso and extremities quickly
  6. Inspect  umbilical cord. Check for area of bleeding or foul odor. Use betadine or 70% alcohol.
  7. Cleanse genital area of infant
  8. Bathe buttocks  using gentle, patting motion

Rationale:

  1. Start from the cleanest areas.
  2. Prevents irritation of the skin.
  3. Prevents cradle crap from forming especially over the frontal head
  4. Expose the neck for more thorough cleansing
  5. Prevents unnecessary exposure and chilling
  6. Minimizes colonization by bacteria
  7. To prevent infection and edema
  8. Keep area clean and dry  to prevent rashes

Nutritional Considerations:

  1. Promote breastfeeding
  2. Provide adequate nutritional intake
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