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A detailed care plan for a neonate patient, including the patient's demographics, medical history, physical assessment, medication administration, and prioritized nursing diagnoses with corresponding nursing interventions and expected outcomes. The care plan covers key aspects of neonatal care such as airway management, thermoregulation, and umbilical cord care, with a focus on educating the patient's mother on proper care techniques. The document serves as a comprehensive guide for nursing students or healthcare professionals caring for a newborn patient in a clinical setting.
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[Date]
Clinical Date:…. Demographics : Patient initials: B.T Age: 2 days old Religion: None Allergies: NKDA History: Chief Concern: Labor Past medical/surgical history: Pre term, streptococcal infection group B, lack of prenatal care Current medical history: Estimated Date of Delivery 6/28/13 (40weeks). Mother was admitted to the hospital for spontaneous vaginal delivery, mother is not GBS pos this pregnancy. Obstetric history: G: 3 T: 1 P: 2 A: 0 L: 2 Year Delivery type (NSVD, LFD, vacuum, CS, SAB, TAB) Weeks gestation Sex Living c patient? 2013 Spontaneous rupture of membranes precipitous home 36 M Y delivery with EMS present 2010 Preterm labor, vaginal delivery 37 M Y 2008 Miscarriage 16 N/a No Labor history: LMP: Unknown due to lack of pre natal care.
Labor onset date, time: 6/05/2013 @ 0229 ROM date, time: Spontaneous ROM Color: unknown due to precipitous labor Delivery date, time: 6/ 5/13 @ 0229 type: vaginal Pain scale: 0 Pain control method: Percocet, Toradol Current Orders:
[Date] Diet: Regular Activity: as tolerated Treatments: Incentive spirometer Postpartum assessment: PHYSICAL ASSESSMENT Newborn assessment: Birth date, time: 6/5/13 Delivery type: Precipitous vaginal del Apgar: no listed due to home delivery Weight birth: 5lbs 3oz Weight today: 5lb Ballard: 37 Length: 48.3 cm Head circle: 33 cm Chest circumference: 26.7cm Mom blood type: o- Baby blood type: o+ GBS status: negative Newborn physical exam (head to toe): Patient observation Vital signs T- 97. Temp HR-172, regular HR R- 64bpm, unlabored, R Skin Warm and dry to touch, no visible birth marks, redness, edema to umbilical cord or surrounding area. Head Rotates freely, fontanels palpable, no bulging, suture lines overlap slightly. Rotates freely Eyes, ears, nose Eyes open spontaneously clear, no redness or drainage, positive blink reflex. Nose patent and clear of mucus, breaths through nose with some nasal flaring. Mouth Opens evenly when child cries, slight mucous in mouth. Neck, chest Chest rises and falls symmetrically. Neck is chubby with skin folds. Hr 168 bpm 54 Abdomen Slightly protuberant, bowel sounds present in all four quadrants, umbilical cord brown. Genitalia Circumcision was held until child is in a healthier state. scrotum is edematous with skin folds.
[Date]
Born to a 20 y.o mother via Vaginal delivery G3 T1 P A L
[Date] Sanoski & Deglin, 2011) LAB DATA & DIAGNOSTIC EVALUATION Include date CITE SOURCE FOR EACH VALUE AND INDICATION LAB Ordered WBC Client Values
Normal Values 9.0-30.0 k/ul (Corbett & Banks, 2012). Indication for Diseases / Illness
LAB Ordered Blood culture Client Values Gram positive rods Normal Values Negative (Corbett & Banks, 2012). Indication for Diseases / Illness The finding of a single positive culture for a Corynebacterium species, P. acnes, or Bacillus species may represent nothing more than contamination.However a second culuture was sent to lab for review and results take 24hrs and are still pending. (Corbett & Banks, 2012). MEDICAL DIAGNOSIS CITE SOURCE
7 10/07Rev^ &^ Approved^ RN^ Program^ Director & Faculty Sara Bernard 6/5/
Student Name: Date: 6/7/13 Class: OB Patient Initials: NURSING DIAGNOSIS (NANDA APPROVED)
(Measurable Goal)
(What do you plan to do?)
(Why are you doing this?) Cite Source for Each Rationale
(Include your measure in your evaluation) Risk for ineffective airway clearance r/t presence of mucus in mouth and nose at birth. (Pillitteri,
Short Term Goal: Neonate will maintain resp rate of 30- breaths per min. without evidence of retraction or grunting during 12 hr shift. Short Term Interventions:
8 10/07Rev^ &^ Approved^ RN^ Program^ Director & Faculty Sara Bernard 6/5/ Long Term Goal: Mother will be able to properly remove mucus from newborn’s mouth and nose with bulb syringe by discharge.
Risk for ineffective thermoregulation r/t newborns transition to extrauterine environment. (Pillitteri, 2010) Short Term Goal: Newborn maintains axillary temp of 98.6 F during 12 hr. shift. Short term interventions:
10 10/07Rev^ &^ Approved^ RN^ Program^ Director & Faculty Sara Bernard 6/5/ Long Term Goal: Mother will be able to prevent heat loss of the newborn by discharge. newborn. Long term interventions:
11 10/07Rev^ &^ Approved^ RN^ Program^ Director & Faculty Sara Bernard 6/5/ Risk for infection r/t newly clamped umbilical cord. (Pillitteri, 2010) Short Term Goal: Umbilical cord will remain free of infection during 12hr shift. . Long Term Goal: Mother will properly demonstrate care of the umbilical cord by discharge. Short term interventions:
13 10/07Rev^ &^ Approved^ RN^ Program^ Director & Faculty Sara Bernard 6/5/ how to properly care for site.
References Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook an evidence-based guide to planning care. (9th ed.). St. Louis,Missouri: Mosby Elsevier. Corbett, J., & Banks, A. (2012). Laboratory tests and diagnostic procedures with nursing diagnoses. (8th ed.). New Jersey: Pearson. Lillis, C., Taylor, C., Lemone, P., & Lynn, P. (2011). Fundamentals of nursing. (7th^ ed). Philadelphia,PA: Wolters Kluwer Health, Lippincott Williams & Wilkin. Pillitteri, A. (2010). Maternal & child health nursing, care of the childbearing & childrearing family. (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2011). Davis's drug guide for nurses. (13th ed.). Philadelphia : F.A. Davis Company. 11 Rev 10/07Approved MCI RN Program 9/07 MLW