NUR 112 / NUR 112 Normal Newborn Case Study UNFOLDING Reasoning

Normal Newborn Primary Concept Reproduction Interrelated Concepts (In order of emphasis) • Thermoregulation • Nutrition • Perfusion • Pain • Clinical Judgment • Patient Education • Communication • Collaboratio ...

Normal Newborn 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 Safe and Effective Care Environment • Management of Care 17-23% ✓ • Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12% ✓ Psychosocial Integrity 6-12% ✓ Physiological Integrity • Basic Care and Comfort 6-12% ✓ • Pharmacological and Parenteral Therapies 12-18% ✓ • Reduction of Risk Potential 9-15% ✓ Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. UNFOLDING Reasoning Baby Boy Jones, 1 hour old • Physiological Adaptation 11-17% ✓ 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 without the use of pain medications or an epidural. 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. 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 at 36 weeks and 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 of age - G1P1 - Gave birth at 39 weeks gestation - Apgars score of 8 and 9 - Gave erythromycin on eyes - Weighs 7lbs 20 inches - Mom is positive for rubella - Vit K and hep B vaccine given - GBS positive - Teen mom so education should be provided as well as social - First baby so lots of info and teaching might be needed - Full term baby = should be a normal healthy baby - This score falls on the normal healthy side - prevent bacterial infections or STI’s that can be passed from mom - this is considered a normal size healthy baby - mom has antibodies and is immune to rubella - this helps prevent blood clots and hep b is for protecting baby from hep b - baby temp should be monitored since mom is GBS pos RELEVANT Data from Social History: Clinical Significance: - has her mother for support - father of the baby is not involved - mom is tired but is holding and interacting with baby - the teen mom has support from her mother and can help guide her and be there for her - mom is a single parent - it is a good sign that mom is engaged with her newborn and is just tired from giving birth Patient Care Begins: You complete your assessment: Current VS: P-Q-R-S-T Pain Assessment: T: 97.0 F/36.1 C (axillary) Provoking/Palliative: P: 130 (regular) Quality: R: 50 (irregular) Region/Radiation: BP: none taken Severity: NIPS score 0 O2 sat: pink in color/no central cyanosis noted Timing: What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. RELEVANT VS Data: Clinical Significance: - T: 97.0 F - P: 130 (regular) - R: 50 (irregular) - O2 Sat: pink in color - NIPS 0 - This is below normal of (97.7-100.4 F) should keep baby swaddled up with a hat for extra warmth or placed under the radiant warmer until temp is normal and should continue to be monitored - Pulse is within normal limits (110-160) - is within limits (30-60) baby and babies usually have irregular breathing - Normal limits - Baby is not in pain. No intervention needed Current Assessment: GENERAL APPEARANCE: Calm, quiet, and in a crib next to the bed. RESP: Lusty cry, breath sounds clear, irregular, non-labored respiratory effort, no nasal flaring, no grunting noted. CARDIAC: Pink, warm & dry, heart sounds regular with no abnormal beats, pulses strong, acrocyanosis present in hands and feet, no central cyanosis noted. NEURO: 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: Clinical Significance: - Calm, quiet, and in crib next to bed - Lusty cry, breath sounds clear, irregular, non-labored, no nasal flaring, no grunting - 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 - Baby is not showing any signs of distress, is happy, and is doing well - Is healthy and strong with all normal findings but should continue to be monitored - All normal findings, heart sounds should be regular with no abnormal beats, pulses are strong where it should be, and acrocyanosis is normally seen in healthy newborns, and cyanosis is not present which indicates a good sign - All within normal but will continue to be assessed for any changes. Fontanelles that are sunken indicate dehydration and those that are bulging indicates abnormalities that should be further assessed Clinical Reasoning Begins… 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: Primary Concept: Low body temperature (97.0 F) Core temperature is a balance between heat production by the body and heat loss to the surrounding environment. Baby is experiencing hypothermia which can be due to an infection or low blood glucose sugars