SBAR NICU - Peds clinical PDF

Preview

Summary

NICU SBAR care plan...

Description

Ivy Tech Community College NRSG 207 Name: Miranda Phillips Male

Situation

NURSERY SBAR

Date: 4/8/19 Gestational Age @ birth: 38 weeks, 1 day

Delivery Date: 4/7/19

Time: 16:12

Delivery Weight: 8lb 2oz

Current gestational age: 38 weeks, 2 days APGARs: 1 min: 8

5 mins: 9

Current Weight: 8lb 1oz

AGA

Background

NB Medications: Hep B- yes Vitamin K-yes Erythromycin Ointment-yes Reason for admission to NICU: N/A Feedings:

Assessment

Breast #min - mother refused breast feed in the morning. Bottle/Amt- 40 mL @ 0830 NG/OG feed N/A Formula given N/A Void- none to asses Not completed yet

Circumcision? Yes

Stool- none to asses

Hearing: Passed/Not Passed- Not completed yet

NBS Y/N-

Bili- N/A

BP? N/A Blood glucose level? N/A

Recommendation

Concept Map ! 1

Ivy Tech Community College NRSG 207

NURSERY SBAR

Indications (r/t and AEB)

Related to breast feeding as evidence by the mother is inaccurately following the schedule of feeding needed.

Expected Outcome (must be measurable

Concept Map Primary Nursing Diagnosis

and have a specific timeframe)

The mother will understand and repeat the benefits of breast feeding prior to the next feeding.

Deficient Knowledge

Parent Teaching (minimum of 3 detailed components) 1. The nurse will teach the mother that following a feeding schedule (such as feeding the infant q2h while in the hospital) is important for the infant’s nutrition and maintaining a healthy weight.

2. The nurse will demonstrate 3 positions that are ideal for breastfeeding such as: football position, the cradle position, and the side-lying position. All of these positions are comfortable for the baby and the mother.

3. The nurse will teach the mother the benefits of breast feeding for the infant such as: transmitting antibodies from mom to infant to help prevent disease/infections, breast milk is full of the nutrients the infant needs, and helps reduce the risk of SIDS (sudden infant death syndrome).

Intervention #1- Asses the mother’s readiness for learning prior to teaching. Rationale #1- Assessing readiness ensures that the mother will be ready and able to retain knowledge that the nurse is providing her. Intervention #2- Have the mother demonstrate all the positions of breast feeding back to the nurse. Rationale #2- The mother should demonstrate what she was learned by the nurse to ensure it is being done correctly, allowing the nurse to intervene if further teaching is needed. Breastfeeding. (n.d.). Retrieved April 9, 2019, from https://advisoredu.lww.com/lna/document.do? bid=19&did=778499&searchTerm=breastfeeding&hits=breastfeeding ,breastfeed,breastfed,breastfeeeding

2

Ivy Tech Community College NRSG 207

NURSERY SBAR

Newborn Assessment + VS: Newborn is 38 weeks 2 days gestation born vaginally on 4/7/19. The NB’s head circumference at brith was 14 cm. Anterior and posterior fontanelles present, firm and are curved slightly. No deformities of the face present. The baby is latching on well to the mother and to bottles/pacifiers. Bowel sounds present and WNL. Breath sounds are clear, heart sounds regular. Umbilical cord present, yellow-green color. Extremities move WNL. Newborn’s skin in warm, dry, intact. The newborn circumcision site is clean and no bleeding present. The newborn’s VS at 0800 were: 140 HR, 36 RR, and 36.8 T.

Skills performed during shift VS X

Assessment X

IV Start/D/C

IVF

Blood draw

I/O Cath

Insert Foley

Patient Supplies. X

Assist pt to BR

Please list any other skills performed not on this list: 3

Ivy Tech Community College NRSG 207

Medication Scheduled/PRN?

Why ordered?

NURSERY SBAR

3 Common Side Effects

Route ordered

Parent Teaching at bedside

Lidocaine

Local analgesia for pain r/t circumcision

Respiratory depression Bradycardia Seizures

Local Injection

The medication wears off within 10 minutes. Monitor for signs on allergic reaction- such as rash and hives.

Erythromycin

Prevent infection in the eyes after birth

Eye irritation Eye redness Anaphylaxis

Ophthalmic

This medication is used on all infants to prevent eye infections.

Vitamin K

Increase clotting factors in the infant

Bleeding Brusing Pain at site

IM

This medication is given to all infants due to low levels of vitamin K, putting them at an increased risk for bleeding.

Hepatitis B

Prevent the infection of Hep. B in the newborn

Fever Headache Injection site irritation

IM

This is a vaccination that should be given to newborns to decrease the risk of getting infected with Hep B.

If no medications given during your shift, please check here ______ 4...