Newborn Case Study PDF

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virtual clinical case study...

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Normal Newborn SKINNY Reasoning

Baby Boy Jones, 1 hour old

Primary Concept Reproduction Interrelated Concepts (In order of emphasis)  Thermoregulation  Nutrition  Perfusion  Pain  Clinical Judgment  Patient Education  Communication  Collaboration NCLEX Client Need Categories

Percentage of Items from Each Category/Subcategory

Covered in Case Study

17-23% 9-15% 6-12% 6-12%

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6-12% 12-18% 9-15% 11-17%

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Safe and Effective Care Environment  Management of Care  Safety and Infection Control Health Promotion and Maintenance Psychosocial Integrity Physiological Integrity  Basic Care and Comfort  Pharmacological and Parenteral Therapies  Reduction of Risk Potential  Physiological Adaptation Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.

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SKINNY Reasoning

Part I: Recognizing RELEVANT Clinical Data History of Present Problem One hour after Delivery: Anne is a 17-year-old, gravida 1 para 1 who is 39 weeks gestation. She recently experienced a normal spontaneous vaginal delivery on 6/12/2020 at 2300 without the use of pain medications or an epidural. She came in to labor on 6/12/2020 at 0600 stating she had broken her water yesterday at noon. She delivered a baby boy who was placed skin to skin following delivery. You assign Apgars of 8 and 9. Baby voided right after delivery and is due to stool. Weight: 7 lbs. 0 oz. (3.2 kg), 20 inches (50.8 cm) long. After he had his first feeding, erythromycin ointment was applied to his eyes. Vitamin K and hepatitis B vaccine (after consent given) were administered in right and left thigh in the outer aspect of the left thigh. Ann is Group Beta Strep (GBS) positive and received antibiotics 3 doses before delivery, blood type is B-, and rubella positive. Cord blood was sent.

Personal/Social History: Anne has her mother with her for support. She seems to be tired but is holding and interacting with the baby appropriately. The father of the baby is not involved. Anne plans on breastfeeding for “awhile.” Anne still lives at home, and her mother plans to help with the new baby and appears supportive. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential)

RELEVANT Data from Report: Mom is 17 years old G1P1 Did not use pain meds or epidural Water broke at noon the day before delivery and waited to come in until 0600 (almost 36 hours) Baby born at 39wks Baby weight: 7lbs and 20in long Gave erythromycin ointment to baby Mom is positive for rubella Apgar 8 @1 min and 9 @ 5min Vit K and Hep B vaccine administered to baby Skin to skin contact Baby has voided but has not passed a stool Mom is GBS positive with three doses of antibiotics and is Rh negative RELEVANT Data from Social History: Teen mom Anne’s mom is there for support Father of baby is not involved Anne is interacting with baby Plans to breastfeed for “awhile” Has plans for living after birth with the help of her mother

Clinical Significance: Teen pregnancy: ask about social support and provide plenty of education First baby (provide more teaching) After 24 hours of someone’s water breaking you begin to worry about infection Full term baby (good weight and length) Given erythromycin in preventatively if mom had gonorrhea which can cause blindness in the baby Apgar if 8 and 9 is normal Vitamin K promotes blood clotting and Hep B vaccine helps protect the baby Skin to skin is important for connection between mother and baby and helps to promote the release of oxytocin in mom

Clinical Significance: First pregnancy and is a teenager so make sure to give plenty of education about taking care of a baby and warning signs in her own body She has support and care from her mom Anne is a single, need to assess family dynamics Provide Anne with more teaching on breastfeeding Note that Anne is in the “taking in” phase (we want to be monitoring here for attachment)

Patient Care Begins: You complete your assessment: Current VS: T: 97.0 F/36.1 C (axillary)

P-Q-R-S-T Pain Assessment: Provoking/Pall

P: 130 (regular) R: 50 (irregular) BP: none taken O2 sat: pink in color/no central cyanosis noted w/ acrocyanosis

Quality: Region/Radiati NIPS score 0 Severity: Timing:

What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance)

RELEVANT VS Data: Temp: 97 F Pulse: 130 RR: 50 (very high) Baby O2 Sat: baby is pink in color with some cyanosis in extremities NIPS: 0

Clinical Significance: Temperature is low for a newborn: should swaddle for warmth or start skin to skin contact between mom and baby and provide warmed blankets to help raise the baby’s temperature (should be between 97.7-100.4 F) Pulse is within normal limits RR is within normal limits for a newborn and babies tend to be irregular breathers O2 Sats are within normal limits Continue to monitor baby vital signs and check back to make sure baby’s temperature rises to within normal limits Baby falls within normal range on the pain scale (NIPS)

Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: NEURO:

Calm, quiet, and in a crib next to the bed. Lusty cry, breath sounds clear, irregular, non-labored respiratory effort, no nasal flaring, no grunting noted, some apnea noted for less than 10 seconds Pink, warm & dry, heart sounds regular with no abnormal beats, pulses strong, acrocyanosis present in hands and feet, no central cyanosis noted. Fontanelles flat and soft, good tone, slight flexion of arms and legs

What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance)

RELEVANT Assessment Data: -Appears is to be calm and quiet -Respirations are in normal limits, clear breath sounds, no nasal flaring or grunting noises -neuro is within normal limits and has slight flexion of limbs

Clinical Significance: -All assessments are within normal limits -Baby could be tired/newborns are unpredictable which may explain the quiet demeaner and slight flexion as opposed to crying and active movement -continue to monitor and asses for changes

Part II: Put it All Together to THINK Like a Nurse! 1. Interpreting relevant clinical data, what is the primary concern? What primary health-related concepts does this primary problem represent? (Management of Care/Physiologic Adaptation)

Problem: Baby’s low temperature of 97.0 F

Pathophysiology of Problem in OWN Words: The baby might have a problem with thermoregulating -Heat loss -lack of heat production Baby could be hypothermic because of an infection or hypoglycemia.

Primary Concept: Thermoregulation of the newborn baby

Collaborative Care (Newborn Orders): Medical Management 2. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies) Care Provider Orders: Vital signs q 30 mins until stable for 2 hours, then every 4-6 hrs

Rationale: Freq assess vitals to determine if there are any changes/declines

May place skin to skin if vital signs stable

Skin to skin is great for bonding/attachment and helps regulate the temp and glucose/blood sugar of baby

May bathe after 6-8 hours, then bathe prn

Expected Outcome: Newborn’s vital signs stay within normal limits

Ensure that mom and If you bathe too soon you could cause could stress baby have successful to the baby (you also want to keep the vernix on the (and unpainful) breastfeeds Breastfeed PRN, minimum of 8-10 times in baby to protect it from bacteria) -observe for 24 hours. No more than four-hour gap in proper/improper latch feedings. Feed infant based on feeding cues. Healthy for mom and baby to successfully breastfeed Similac/Enfamil 6-10 mL every 3-4 hours based on infant’s feeding cues Recommend and encourage exclusive breastfeeding.

Frequent skin to skin contact with mother or Promotes bonding and attachment and also can partner help regulate newborn temperature

-The baby’s temp will rise and stay between 97.7-100.4 F -Baby’s lose weight Weight at birth and then every evening Babies should get weighed daily to monitor weight after delivery and we need to make sure it gain and loss after delivery does not exceed more Input and Output every shift than 10% if its birth Check how often the baby us voiding to monitor weight digestion and nutrient intake -Panels and screenings Newborn work up (blood type, Coombs) if need to be completed If mom is Rh negative and baby is Rh positive the the mother is Rh negative; cord bilirubin prior to discharge to mother needs to have Rhogam administered make sure a healthy The newborn screen at greater than 24 hours It is important to make sure the baby has fed once baby is sent home and he doesn’t need any before you complete this screening more interventions. -Baby will pass with You want to check the bilirubin to determine the Transcutaneous bilirubin level prior to liver function of the baby (the more yellow the baby normal bilirubin levels, discharge will pass their hearing the higher the bilirubin may be) screening in both ears, Newborn hearing screen before discharge Tests the baby’s hearing ability in each ear (failing and will pass the the test may be a result of leftover fluid in the ear) congenital heart screening. Congenital heart screening You want to check the O2 sat in the finger and foot of baby to determine if the heart is adequately pumping

Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (Management of Care) Prevention of heat loss Nursing PRIORITY: PRIORITY Nursing Interventions: Prevent heat loss and maintain proper temperature regulation

Rationale:

Expected Outcome:

The newborn’s temp is 97.0 F and needs to be at least After skin to skin contact 97.7 F. Low temperature may be an indication of other and use of heated complications such as infection or low blood glucose blankets with baby levels should be able to maintain a temperature Encourage skin to skin contact within the normal range of 97.7-100.4 F Place stocking cap on newborn to retain heat

4. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity/Basic Care and Comfort)

Psychosocial PRIORITIES:

Make sure Anne has all the resources/teachings and proper support system to successfully take care of her first baby.

PRIORITY Nursing Interventions:

Rationale: By providing care and comfort mom will feel more confident and will help to facilitate the best possible outcome for mom and baby. .

CARE/COMFORT:

EMOTIONAL (How to develop a therapeutic relationship): Discuss the following principles needed as conditions essential for a therapeutic relationship:  Rapport  Trust  Respect  Genuineness  Empathy Adaption to the role of mother

Expected Outcome: The nurse educates and answers any questions on procedures or interventions that Anne has.

Being present and available: we want to build a strong Mom openly and trusting relationship. Carry on a conversation and communicates and feels ask her questions about her family planning and to asks questions and provide more resources. talk about her concerns/worries. Active listening (conveying a sense of presence and being engaged in the conversation) Non-judgmental care Answering questions with genuineness and providing advice with empathy to create a good nurse and patient relationship. Through this we are also ensuring that mom us ready for this new role.

SPIRITUAL: (look up FICA assessment Important to understand that all patients have The nurse will respect to assist you in answering) different faiths and beliefs so it is important to provide the patient’s faith,  F-Faith or beliefs: the same level of care to all patients and be able to religion, and culture.  I-Importance and influence understand and allow patients to make decisions  C-Community: based upon their beliefs and cultures  A-Address:

Education Priorities What educational priorities will be needed to develop a teaching plan for this patient and/or family? (Health Promotion and Maintenance)

Education PRIORITY:

PRIORITY Topics to Teach:

Teach mom how to care for her first child.

Rationale:

-How and when to bathe the newborn

This is the mom’s first child and she has had no prior experience with newborns/babies. It is very important to cover all of these topics to ensure that -what a proper latch and hold feels like and the baby is safe and healthy. how often to breastfeed Teaching proper diaper and bathing care is important since mom might not -how to check baby’s temperature and how know how often or how to change or bathe a newborn. Teaching her proper often cleaning care for the umbilical clamp so it does not get infected and teach her what soaps to use and how to sponge bath or wash the baby. Also show her -reasons to call the provider vs what is what size and types of diapers to use and how to properly wipe, change, and normal newborn behavior put a diaper on her baby. -teaching on car seat use and safety (and resources)

Teaching on proper breastfeeding is important. Mom mentioned wanted to breastfeed for “awhile”, so teaching her proper timelines and the pros and cons of breastfeeding and for how long is very important. Also teaching her that -give resources for various support groups: breastfeeding shouldn’t be unbearably painful and if it is the baby probably -breastfeeding moms’ group isn’t getting a proper latch. -teenage moms’ group Teach her how to check her baby’s temperature. What is considered the normal -proper ways to change the baby’s diaper range for babies and at what point to call the doctor. and how to monitor if the baby is having adequate poops and pees for their age Teaching on car seat safety and use. You want the mom to be able to show you that she knows how to properly place the baby in the carrier, buckle them in, and make sure they know how to properly attach the carrier/car seat in the car. You want mom to feel confident when she is discharged and know that there are people out there who can relate and help her during this new stage of life. This is why it is very important to teach her about support groups and provide her with information for groups in her area and how to get connected. O

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