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[Date]
STUDENT NAME:…
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.
EDC: 6/28/
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
MEDICAL DIAGNOSIS
[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
A low white blood cell count, or leukopenia, is
a decrease in disease-fighting cells (leukocytes)
circulating in your blood. (Corbett & Banks,
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/
NURSING CARE PLAN
Student Name: Date: 6/7/13 Class: OB Patient Initials: NURSING DIAGNOSIS (NANDA APPROVED)
EXPECTED
OUTCOME
(Measurable Goal)
NURSING INTERVENTIONS
(What do you plan to do?)
RATIONALE
(Why are you doing this?) Cite Source for Each Rationale
EVALUATION
(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:
- Remove mucus from infant nose and mouth with bulb syringe as needed.
- Assess respiratory rate, depth, labor or unlabored and breathe sounds.
- Document the quality of the newborn cry and assess for periods of crying during the shift. Long Term Interventions: Short Term Rationales:
- It is important to remove secretions from the mouth and pharynx to prevent aspiration. (Pillitteri. 2010)
- Expiratory grunting diminished breath sounds are all signs of respiratory distress. (Pillitteri, 2010)
- A newborn that is crying is also breathing. The sound of crying is made by a current of air passing over the larynx. Short Evaluation: Goal met neonates breaths are kept at 30- per min.
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.
- Teach mother to decompress bulb syringe prior to insertion and never suction vigorously.
- Teach mother to position her newborn’s head down and to the side when suctioning.
- Encourage mother to allow infant to cry at times. (Pillitteri, 2010) Long Term Rationales: 1. Vigorous suctioning can irritate the mucous membrane and lead to an infection. (Pillitteri, 2010) 2. The head-down-and-to-the-side position facilitates drainage. (Pillitteri, 2010) 3. The more lusty the cry, the greater the assurance the newborn is breathing deeply and forcefully. (Pillitteri, 2010) Long Term Evaluation: Goal in progress. NURSING DIAGNOSIS
EXPECTED
OUTCOME
NURSING INTERVENTIONS RATIONALE EVALUATION
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:
- Check axillary temperature every four hours during shift.
- Keep newborn swaddled.
- Encourage mother to hold the Short term rationales:
- Unstable temperature in a newborn may indicate an infection may be present. (Pillitteri, 2010)
- These actions help prevent heat loss. (Pillitteri, 2010)
- Holding a newborn conserves heat and Short term evaluation: Goal in progress
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:
- Teach mother and father how to swaddle newborn correctly with blanket.
- Encourage mother to dry infant quickly after bathing and swaddle in a warm dry blanket.
- Encourage parents to keep newborn’s head covered with a cap immediately after head/hair has been washed. also encourages bonding. (Pillitteri, 2010) Long term rationales:
- Swaddling helps mimic the tight confines of the uterus and offers a sense of security. (Pillitteri,
- This helps prevent rapid heat loss. (Pillitteri, 2010)
- Covering the hair with a cap after drying it further reduces the possibility of evaporation cooling. (Pillitteri, 2010) Long term evaluation: Goal met mother swaddled child as shown. NURSING DIAGNOSIS
EXPECTED
OUTCOME
NURSING INTERVENTIONS RATIONALE EVALUATION
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:
- Inspect the umbilical cord ensuring it is securely clamped.
- Teach parents to wipe umbilical cord with alcohol at each diaper change.
- Keep umbilical cord clean and dry. Long term interventions:
- Explain why not to use creams, lotions, or oils near the cord.
- Encourage parents to give the newborn sponge baths until the cord falls off.
- Teach parents how to fold the diaper back below the level of the umbilical cord. Short term rationales: 1. If a clamp loosens before thrombosis obliterates the umbilical vessels, hemorrhage could result. (Pillitteri, 2010) 2. Wiping the cord at each diaper change helps to hurry drying and possibly reduce the development of infection. (Pillitteri, 2010) 3. Prevents infection. (Pillitteri, 2010) Long term rationales: 1. These products slow the drying process of the cord and invite infection. (Pillitteri, 2010) 2. Prevents the umbilical cord from becoming immersed in water during a bath. (Pillitteri, 2010) 3. This keeps the cord from getting wet when the diaper is wet. (Pillitteri,2010) Short term evaluation: Goal met no sign of irritation or infection on or near umbilical cord. Long term evaluation: Goal met nurse used blue phone to communicate to mother in Spanish and mother demonstrated
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
