NR_327___Newborn_Teaching_ISBAR

NR327 ISBAR Teaching Prenatal and Newborn Care Documentation New: May20 I-SBAR for Direct Patient Care Documentation Teaching Prenatal and Newborn Care I INTRODUCE YOURSELF Your Name: Your Title: Reason for Being ...

NR327 ISBAR Teaching Prenatal and Newborn Care Documentation New: May20 I-SBAR for Direct Patient Care Documentation Teaching Prenatal and Newborn Care I INTRODUCE YOURSELF Your Name: Your Title: Reason for Being There: Patient care Date: 05/09/2020 Time: 0700NR327 ISBAR Teaching Prenatal and Newborn Care Documentation New: May20 S SITUATION Patient initials: CC Age: 28 G 1 T 0 P_0_A_0_L_0__ Diet: Regular Height: not available Weight: not available EDD: not available LMP: not available Trimester: third □ Singleton □ Twin □ Other Reason for visit: birth Fetal movement: □ present □ not present Allergies: NKA Obstetrician: Trimble, George Pediatrician: Patel, Aanya B BACKGROUND Previous pregnancies NONE Year Type of delivery Labor Length Complications Current pregnancy Prenatal care: □ yes □ no Breast feeding: □ yes □ no Blood type/Rh: ______ Rubella:_____ Hep B: _______ HIV:_______ RPR: ______ GBS status: ______ Complications: gestational diabetes Past Medical History: _____________ Social History: employed Family Support: married, living with spouse A ASSESSMENT Newborn: Initials: CC □Boy □Girl Delivery method: vaginal Birthdate: 09/18/XX Time: 0415 Apgar score – not available Resuscitation measures: full code Birth weight 8 lb. 0 oz. g. Length: 52cm in/cm Head:___ in/cm Chest:____ in/cm Gestational Age Category: SGA: AGA: LGA: _ Safety checks: ID bands_______ Security Sensor:____ _ Bulb syringe: Newborn Vital Signs: TEMP B/P HR RR SP02 PAIN FHTs 36.8 ax Not available 144 36 Not avail. Not avail 36.9 ax Not avail 152 42 Not avail Not avail 36.8 ax Not avail 138 40 Not avail Not avail Newborn Input & Output: DATE Time Breastfeedin g (min) LATCH Score Formula (mL) Urine Stool 09/19/XX 0425 20 8 none X1NR327 ISBAR Teaching Prenatal and Newborn Care Documentation New: May20 09/19/XX 0810 30 7 none X1 09/19/XX 1050 25 8 None Teaching Topics: What teaching should be included in the topics below? Be Specific and Concise Birth Plan IV pain medications; physical/emotion changes; pregnancy complications; birthing options; maternal adaptation; nutrition during pregnancy; feeding option/breastfeeding; Skin-to-skin contact; APGAR scoring Pain Management IV pain medications; epidurals; hydrotherapy; Doulas; breathing exercises Umbilical Cord Care The parent should cleanse the skin at the base of the cord with plain water if soiled. The parent should then dry the site thoroughly. Delayed Cord Clamping Risks/benefits; performed 25sec – 5min after giving birth; allows more blood to transfer from the placenta to the baby Skin to Skin Helps maintain body temp and decreases the risk of hypothermia; assists NB in transitioning to new environment; promotes breastfeeding; glucose regulation Circumcision Care Circumcision site should be washed gently with plain, warm water. Soap should be avoided until the area is healed in about 5-6 days. Vitamin K Helps the blood to clot and prevents serious bleeding; can prevent potentially fatal VKDB/HDN Erythromycin Ophthalmic Ointment Erythromycin ophthalmic ointment is administered to a NB w/i 2hr of birth to prevent ophthalmia neonatorum Hepatitis B Vaccine Hep B vaccine requires the parent/guardian to sign an informed consent form prior to administration. Hep B is given IM into vastus lateralis in NB APGAR Scoring Conducted at 1min after birth and 5min after birth. Appearance, Pulse, Grimace, Activity, Respiration; test to determine if medical care/emergency care is needed Infant Abduction Preventions ID bands should remain on the newborn during hospitalization to ensure proper identification. The parents should remove the ID bands after hospital discharge Blood Glucose monitoring (newborn) Necessary for babies born to mothers who had diabetes before pregnancy; blood is taken from baby’s heel; breastfeeding prevents drop in BgL Heel stick Procedure The outer aspect of the heel should be used for the puncture site. Hypoglycemia Jitteriness is a manifestation of hypoglycemia; other manifestations include a weak cry, tachypnea, episodes of apnea, and seizures Breastfeeding Benefits Strong immune system; lower risk from allergies; lower risk of obesity; optimal brain development; lower incidence of SIDS; lower risk for ear infections; optimal oral development; better response to immunizations Breastfeeding Positions Cradle hold; cross-cradle hold; clutch position; side-lying position; positioning should always feel comfortable; infant should be positioned so that they’re facing the mom’s body, with proper body alignmentNR327 ISBAR Teaching Prenatal and Newborn Care Documentation New: May20 Plan of Care Nursing Analysis/ Priority Diagnosis: Risk for maternal injury r/t changes in diabetic control Patient Goal: Patient will remain normotensive and maintain normoglycemia, by discharge Outcome Criteria: BP WNL and BgL WNL Met/ Not met/ partially met Priority Interventions Reasoning Evaluation of intervention 1. Assess and monitor for s/s of edema Because of vascular changes, the diabetic client is prone to excess fluid retention and PIH. The severity of vascular changes prior No edema noted Newborn Feeding Cues (early and late) Rooting reflex; sucking on hands; open mouth; hand-to-hand movements; mouthing Swaddling Should be enough space for 2-3 adult fingers between the blanket and the baby’s chest. Prevents overheating/compromising the NB’s ability to breathe. NB’s legs should be slightly flexed and abducted when swaddled, and the blanket should be loose enough to allow free movement of the knees. Bulb Syringe procedure The parent should suction the NB’s mouth first, then the nostrils. This will prevent aspiration of secretions from the mouth or throat during nasal suctioning. Diaper Changing Place baby on clean, soft, safe surface; open diaper/clean baby; discard dirty diaper; dress baby; wash your hands again Newborn Bath The parent should begin the bath by washing the face with plain, warm water; trunk/ extremities are then washed with warm water and mild soap; diaper area next; hair washing should be done at the end of the bath; parent should dry/swaddle the NB prior to washing hair to decrease risk of hypothermia Safe sleep To ensure the NB’s safety and decrease the risk for SIDS, the parent should avoid the use of bumper pads because they are a suffocation hazard. R RECOMMENDATION Discharge Planning Needs: Postpartum nutritionNR327 ISBAR Teaching Prenatal and Newborn Care Documentation New: May20 to pregnancy influences the extent and time of onset of PIH. 2. Determine fundal height Hydramnios occurs in 6-25% of pregnant diabetic clients. May be associated with an increased fetal contribution to amniotic fluid because hyperglycemia increase fetal urine output. Fundal height WNL and expected 3. Identify for episodes of hyperglycemia Diet and/or insulin regulation is necessary for normoglycemia, especially in 2nd and 3rf trimesters, when insulin requirements usually doubled. No hyperglycemia noted 4. Identify for episodes of hypoglycemia Hypoglycemic episodes occur most frequently in the 1st trimester, owing to continuous fetal drain on serum glucose and amino acids, and to low levels of HPL. In the presence of hypoglycemia, vomiting may lead to ketosis. No hypoglycemia noted 5. Assist client in learning home monitoring of blood glucose, to be done a minimum of 4 times/day. Allows greater accuracy than urine testing because the renal threshold for glucose is lowered during pregnancy. Facilitates tighter control of serum glucose levels. Patient verbalizes understanding