Anda di halaman 1dari 17

1

PATRICK HENRY COMMUNITY COLLEGE CARE PLAN FOR NURSING 118: MATERNAL/CHILD NURSING NEWBORN Student Name: Brittany Wood Date of Clinical: 9-15-2011 Date Submitted: 9-19-2011 Instructor Use Only: Satisfactory_____ Unsatisfactory___ Date___________ Instructor______________________________ Student Review Signature_________________

Demographic Data: Date of Delivery: September 13, 2011 Sex: Male Age: 2 days old Time of Delivery: 1322 PM Gestational Age: 40 weeks 3 days

Gestational age by Dubowitz assessment: 38 weeks____________________________ Birth weight: Weight today: Grams: 3917 Grams: 3672 Pounds: 8 lbs Pounds: 8 lbs Ounces: 10.2 oz Ounces: 1 oz

Is newborn small, large, or appropriate weight for gestational age? Large (LGA) Apgar Scores: 1 minute: 8 5 minutes: 9

Fetal complications: LGA, and Jaundice Medications received by mother during labor and delivery: Nubain 20 milligrams

Resuscitative measures: N/A

Blood Type: Maternal: B-

Newborn: B+

Coombs: Not necessary for newborn

Breast or Bottle Feeding: Breast feeding

MEDICATIONS GIVEN SINCE DELIVERY MEDICATION/DOSAGE ROUTE/FREQUENCY Drug: Vitamin K Dose: 0.5 mg Route: injection IM Site: Left Thigh NURSING RESPONSIBILITIES Monitor for frank and occult o Vitamin K is needed for bleeding. blood clotting. Monitor pulse and blood pressure o Babies are born with very frequently; notify physician small amounts of vitamin immediately if symptoms of internal K in their bodies. This puts bleeding or hypovolemic shock them at risk of hemorrhagic develop. disease of the newborn Newborns should be observed for (HDN). vitamin K deficiency. o As a preventive measure, The incidence of vitamin K babies are routinely given deficiency is higher in breast-fed vitamin K injections at infants. birth. In infants (particularly premature babies), excessive doses of vitamin K during the first few days of life may cause Hyperbilirubinemia; this in turn may result in severe hemolytic anemia, hemoglobinuria, and kernicterus, leading to brain damage or even death. o To promote active In neonates inject the vaccine into the anterolateral thigh, avoiding blood immunity in individuals at vessels and nerves. high risk of potential exposure to hepatitis B Carefully aspirate to prevent virus or HBsAg-positive inadvertent intravascular injection. materials. Have epinephrine immediately o Has been used available to treat anaphylaxis. simultaneously with Shake vial well before hepatitis B immune withdrawing dose to assure uniform globulin (H-BIG) for postsuspension. exposure prophylaxis in Monitor for adverse reactions: selected patients and in Mild local tenderness at injection infants born to HBsAgsite positive mothers. Local inflammatory reaction (swelling, heat, redness, pain) Fever Malaise Fatigue Nausea Vomiting Diarrhea Rash Urticaria Pruritus

RATIONALE

Drug: Hepatitis B MERCK/Recombivax HB Dosage: 5mcg Route: Injection IM

Erythromycin or tetracycline o Ophthalmic Ointment

Part of the routine care of the newborn is to give prophylactic eye treatment against gonorrhea conjunctivitis or opthalmia neonatorum. o Neisseria gonorrhea, the causative agent, may be passed on the fetus from the vaginal canal during delivery

Apply over lower lids of both eyes Manipulate eyelids to spread medication over the eyes Monitor for irritation Provide mother with information regarding purpose and information of the administration of ointment.

MEDICAL PROCEDURES TREATMENT Circumcision: The procedure was to be completed after I had left the clinical site. Was to be performed before discharge 9-15-2011
RATIONALE

o Circumcision is the removal of the foreskin, which is the skin that covers the tip of the penis. o In the United States, it is often done before a new baby leaves the hospital. o There are medical benefits and risks to circumcision. o Possible benefits include a lower risk of urinary tract infections, penile cancer and sexually transmitted diseases. o The risks include pain and a low risk of bleeding or infection (these risks are higher for older babies, boys and men)

NURSING RESPONSIBILITIES Provide parents with sufficient information to make an informed choice. Promote comfort and healing. Identify and minimize postoperative complications. Instruct parent(s) in proper care of circumcised infant.

NB Lab Screening: 9-13-2011 Age at which collection was obtained: 32.9 hours old 9-13-2011 - Cord Blood PH: 7.36 - ABO/RH ABO: B pos 9-14-2011 - TOT Billirubin: 8.8 H - DIR Billirubin: 0.3 H 9-15-2011 - TOT Billirubin: 9.4 H

o Every infant born in the United States is screened shortly after birth for a number of genetic disorders. o Serious problems, including mental retardation and death, can be prevented if the disorders are discovered early through newborn screening. Total Bilirubin levels in newborns up to 7 das old:
Premature baby < 8.0 mg/dL or < 137 mmol/L < 12.0 mg/dL or < 205 mmol/L < 15.0 mg/dL or < 256 mmol/L < 15.0 mg/dL or < 256 mmol/L Full-term baby < 6.0 mg/dL or < 103 mmol/L < 10.0 mg/dL or < 170 mmol/L < 12.0 mg/dL or < 205 mmol/L < 10.0 mg/dL or < 170 mmol/L

Age

< 24 hour s

< 48 hour s

The skin of the heel is first cleaned with alcohol Puncture the heel with a small sterile lancet. Collect several drops of blood in a small tube. When enough blood has been collected, place a gauze pad or cotton ball over the puncture site. Pressure is maintained on the puncture site briefly. Apply small bandage. Preventive measures as frequent feedings during the first 6 to 12 hours of life to increase GI motility have little justification. Infants with mild jaundice require no treatment, only observation. Phototherapy is the usual treatment for severe or increasing hyperbilirubinemia.

9-13-2011 Glucose: - Birth: 67 mg/dL LOW - 2nd: 69 mg/dL LOW - 3rd: 68 mg/dL LOW

3 to 5 days

7 days

Early feeding: Encourage the mother to feed frequently, especially if the baby is sleepy or not keen. Promote skin-to-skin contact: This encourages breastfeeding; it also keeps your baby warm, which lowers the risk of hypoglycemia. Recheck blood glucose after interventions: Should always be first priority to determine if interventions were successful. Once glucose levels stabilize work with the mother to form a routine feeding schedule

Normal Glucose Level: Newborn: 80-90 mg/dL Glucose checks reveal LOW blood sugar Persistently low glucose levels increase the risk of hypoglycemia in the newborn!

Coombs Screening if indicated: Not indicated for newborn patient

The test is looking for "foreign" antibodies that are already adhered to the infant's RBCs, a potential cause of hemolysis. This is referred to as antibodymediated hemolysis. The two most commonly recognized forms of antibodymediated hemolysis in newborns are Rh incompatibility and ABO incompatibility.

NURSING DIAGNOSES Evaluation

InterventionsNursing

poration.

Provide neutral thermal environment per radiant warmer.

Immediately after birth dry the infant stimulating circulation through out the body.

DataSupportive

m adaptation to extra-uterine life. Newborns lose body heat, and lose it rapidly, 4 ways because their neurological systems are not fully developed at birth:

DiagnosisNursing Risk for Ineffective Thermoregulation R/T immature compensation for changes in environmental temperature.

Goal Maintaining a temperature of 98.5 Fahrenheit. Newborn will demonstrate effective thermoregulation AEB:

10

Evaluation Infant displays no evidence of eye irritation. Goal Met AEB:

ined within normal limits.

No symptoms of dehydration were noted upon assessment.

11

InterventionsNursing

Shield skin exposure eyes certain that lids are closed before applying shield to prevent corneal irritation eyes, axillary temperature t, to increase body surfacenude under light for maximum infant's Checkmake each shift for drainage or irritation Place infant exposure

12

DataSupportive 9/14/11: 0.3 MG/DL HIGH8.8 MG/DL HIGH Newborn labs revealed high levels of billirubin:

9/15/11: .4 MG/DL HIGH

HIGH INTERMEDIATE

13

DiagnosisNursing Risk for injury r/t therapeutic treatment: Phototherapy

Goal Infant remain free of injury AEB:

No evidence of eye irritation, dehydration, temperature instability, or skin breakdown.

14

DataSupportive

Nursing Interventions

Evaluation

15

InterventionsNursing

Evaluation

DiagnosisNursing Large Gestational AgeRisk for hypoglycemia r/t

Goal

16

DiagnosisNursing

DataSupportive

Goal

17

Anda mungkin juga menyukai