Student-Normal Newborn- Skinny Reasoning PDF

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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. Anne 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:          

Clinical Significance:

Mom is 17-years-old Gravida 1 para 1 (1st pregnancy and 1st child) Had baby at 39 weeks Baby’s weight is 7 lbs and 20 in Give ointment on eyes Mom is positive for rubella Apgar’s of 8 (1 min) and 9 (5 min) Vitamin K, Hepatitis B vaccines given to baby Skin-to-skin Baby voided, due for stool

RELEVANT Data from Social History: 

  



Teen mother (17-years-old) G1P1 first child Grandmother is there for support Father of baby is not involved Mom plans on breastfeeding for undetermined amount of time Mom is tired but is holding and interacting with baby

        

Teen pregnancy: assess social support and provide lots of education First baby: need to provide thorough education The baby was born at full-term so we expect a happy healthy baby AGA: average for gestational age If Mom has Gonorrhea, may pass to baby during birth, cause blindness Mom does not need an additional MMR vaccine because she has antibodies Apgar of 8 and 9 is normal Vitamin K promotes blood clotting and the Hep B vaccine protects the baby Skin-to-skin is important for Mom and baby as Mom will release oxytocin to prevent postpartum hemorrhage and baby will have better temperature regulation and help with blood glucose levels

Clinical Significance:  

 

Ensure Mom has education as this is her first child and has social support at home Grandmother is supporting Mom which is helpful to know since she is a teen mother Noted that Mom is a single parent, assess family dynamics Chart Mom is bonding with the newborn even though she is tired

Patient Care Begins: You complete your assessment: Current VS: T: 97.0 F/36.1 C (axillary) P: 130 (regular) R: 50 (irregular) BP: none taken O2 sat: pink in color/no central cyanosis noted w/ acrocyanosis

P-Q-R-S-T Pain Assessment: Provoking/Pall 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:  Temperature: 97.0 F  Pulse: 130 (regular)  Respirations: 50  

(irregular) Oxygen saturation: baby is pink in color, some cyanosis on extremities NIPS score 0

Clinical Significance:  Temperature is slightly below normal (97.7 F up to 100.4 F is normal)  Make sure to continue to monitor baby’s temperature because Mom was GBS positive even though Mom received treatment  Pulse is within normal limits  Respirations is within normal limits, babies are irregular breathers  Oxygen saturation is within normal limits  No red flags or issues with the newborn vital signs, important to chart and continue to monitor for any changes/decline  No interventions are necessary because the baby is comfortable and is not in pain

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:  General appearance is calm and quiet  Respirations are within normal limits, breath sounds clear, no nasal flaring, no grunting noted  Neuro is within normal limits, slight flexion

Clinical Significance:  All are within normal limits and the baby is happy to be there and doing well  Baby may be tired which may explain why the baby is quiet and there is slight flexion of extremities instead of active movement  Continue to monitor and assess for any changes/decline

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:

Pathophysiology of Problem in OWN Words:

The baby’s body The baby may have a problem thermoregulating their temperature. temperature is low Thermoregulation is the ability to balance heat production and heat loss. The (97.0 F) baby is hypothermic and this could be due to an infection or hypoglycemia, which is why it is important to check the baby’s blood glucose level. It is also important to have skin-to-skin contact so Mom’s breasts can adjust to help the baby’s temperature.

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: Frequently assess the baby’s vital to determine if there are any changes/decline

May place skin to skin if vital signs stable

Skin-to-skin is helpful for bonding, helps regulate the temperature and glucose/blood sugar of the baby

Expected Outcome: We would like the newborn baby to stay within normal limits

May bathe after 6-8 hours, then bathe prn If you bathe too soon, you may cause cold stress to Ensure the Mom can the neonate, also want to keep the vernix on the babytolerate breastfeeding, may be painful due to to help protect from harmful bacteria improper latch Breastfeed PRN, minimum of 8-10 times in Healthy for Mom and baby to breastfeed (Mom’s 24 hours. No more than four-hour gap in body releases oxytocin which helps contractions and feedings. Feed infant based on feeding cues. prevents postpartum hemorrhage) Recommend and encourage exclusive breastfeeding.

Similac/Enfamil 6-10 mL every 3-4 hours based on infant’s feeding cues

We would like to make sure the baby’s temperature goes up to normal (at least 97.7 F and no higher than 100.4 F – monitor varies depending on facility)

Frequent skin to skin contact with mother or Helps regulate baby’s temperature and promotes bonding between Mom and baby partner

Weight at birth and then every evening

Input and Output every shift

Newborn work up (blood type, Coombs) if the mother is Rh negative; cord bilirubin

Babies lose weight after delivery, we should to make sure they are receiving enough nutrients and food Check how often the baby is voiding (pee/poop) If Mom is Rh negative and baby is Rh positive, it is important to provide rhoGAM within 72 hours

The metabolic screening tests for 34 different problems, it is important this is after 24 hours to The newborn screen at greater than 24 hours ensure the baby has some food in their body

Transcutaneous bilirubin level prior to discharge

Newborn hearing screen before discharge

Congenital heart screening

Babies lose weight after delivery, ensure it does not exceed more than 10% of its body weight

We complete all of the screenings, panels, and tests prior to discharge to ensure baby is healthy and does not need any additional interventions

This checks the liver function of the baby and the more yellow the baby is, the higher the bilirubin level may be

Expectation is the baby has normal bilirubin levels, passes the congenital heart and newborn hearing The newborn hearing screening is to test is baby can screening. If the baby does hear, sometimes retests are needed if baby was a c- not pass the congenital heart screening an echo may be section because of fluids in ears needed.

Check the oxygen saturation on the finger and foot, if there is not a 3 point difference the heart is pumping adequately

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

Rationale: The newborn’s temperature is 97.0 F, when we would like the temperature to be at least 97.7 F. If the baby is hypothermic, there may be other problems such as an infection or inadequate blood glucose levels.

Expected Outcome: After interventions such as skin-to-skin contact with Mom and putting on a heated blanket the newborn’s temperature rises to a normal level.

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

Psychosocial PRIORITIES:

Ensure Mom has all the possible resources and support system to take care of her newborn baby

Rationale: Expected Outcome: CARE/COMFORT: Show the patient we We would like to provide the best care and support for The nurse educates and our patient and ensure the best possible outcome for obtains consent on all are there for them. Allow Mom to ask Mom and baby. procedures and anything on her mind. interventions. Build a strong, healthy relationship with Mom to gain Mom is honest with us EMOTIONAL (How to develop a her trust. We may show we care by comforting our and voice and questions therapeutic relationship): Discuss the following principles needed patient (but not overstepping any boundaries). We may or concerns if there is a as conditions essential for a ask questions such as future family planning, and offer strong relationship resources and education regarding birth control, between the nurse and therapeutic relationship:  Rapport transportation, and car seat safety. Also, ensure the patient. Mom is ready to take on this new role.  Trust  Respect  Genuineness  Empathy

PRIORITY Nursing Interventions:

Adaption to the role of mother SPIRITUAL: (look up FICA assessment We want to understand our patients and know what their faith or beliefs are to help guide teaching and to assist you in answering) provide the best care.  F-Faith or beliefs:  I-Importance and influence  C-Community:  A-Address:

The nurse respects the patient’s faith, religion, and beliefs.

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:        

How often and how to bathe the newborn How often and how to properly latch and breastfeed How often and how to check temperature for your baby Warning signs to call the provider Provide resources and guidance on car seat use and safety (but not touching or putting the newborn in the car seat) Provide resources such as a support group for breastfeeding mothers How to change the baby’s diaper Provide resource for a support group for teenage mothers

Teach Mom how to properly take care of her first child

Rationale: This is the Mom’s first child and since she reported no prior experience it is important to cover all necessary topics to ensure the baby will grow happy and healthy. Teaching mom how to change a diaper and bathe the newborn is a priority because Mom may not know how often the bathe the baby or which soap to use, types/size of diapers etc. Breastfeeding is also a priority topic because Mom reported wanting to breastfeed for “a while” and this is how the baby will receive its food. Latching is important because it may be painful for Mom if the baby does not latch properly when breastfeeding. Checking temperature and knowing the normal temperature ranges is important because it may be a sign of infection. We will emphasize what warning signs to look out for and when to call the baby’s provider. Educating Mom on various resources such as the Fire Department for car seat safety and support groups is helpful so she feels confident upon discharge is a priority....