Careplan on Neonate
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PATIENT’ S BIODATA
NAME: Baby of Mr.sureshbhai makawana
AGE: 1st day
DATE OF ADMISSION:7/12/10
DIAGNOSIS: Respiratory distress with non vigorous me conium aspiration
NAME OF FATHER: sureshbhai makwana
NAME OF MOTHER: Induben makawana
ADDRESS: Gam,bhat man ta, dholka district, Ahmedabad
CARE STARTED: 7/12/10
CARE ENDED: 9/12/10
Baby not cried immediately after birth. She is having apnea at birth and non vigorous aspiration of meconium stain liquor. Apgar score is 8/9. Resuscitation per positive pressure ventilation for 2 minutes and transferred to nursery under free oxygen per face mask. Admitted to nursery with special care nursery orders, medical diagnosis RDS and non vigorous mecomium aspiration ; weight is 2.130 kg. Mother is 23 years old, primi gravid and experiencing complicated delivery requiring admission to surgical unit STAT.
HISTORY OF PRESENT ILLNESS:
Newborn is in respiratory distress, bilateral advantageous breath sounds (crackles), with deep intercostal retractions and substernal retractions. Acrocyanosis is noted, but newborn is centrally pink and active.
Ventilator initiated at 40% FiO2, on SIMV mode,RR-75, SPO2-100%, with should roll to maintain open airway position. Newborn is on radiatn warmer with temperature probe to abdomen, incubator set at 37.0C. Axillary temp 97.2F. Warmed and humidified oxygen being administered. Glucose per chemstrip is 65-80 mg/dl.
Peripheral IV started in right hand with 24 guage insyte catheter, D10W infusing per IV at 6 ml/hr. Cardiac/apnea monitor and pulse oximeter monitoring began with regular sinus rhythm of 162, respiratory rate 75, and SPO2 96% while under oxygen support. Blood pressure 55/35. Capillary refill <2 sec, pulses strong and regular all extremities, newborn reflexes present and appropriate.
Oral gastric 5 french tube placed and checked by auscultation. Obtain 5cc clear mucous and 7cc air by aspiration and tube left open to air.
HISTORY OF PAST ILLNESS:
baby not cried immediately after birth. She has respiratory distress after birth
ANTENATAL: Mrs. Induben makawana had regular antenatal visit , also gain weight, no any problem encountered, immunization 2 T.T injection taken.
INTRANATAL: Delivery was vaginal. Birth weight is 2.310 kg. baby not cried immediately after birth. Apgar score is 8 at birth, after 5 min 9.
POSTNATAL: child had respiratory distress.
Mr.sureshbhai Mrs. Induben
FAMILY HISTORY OF ILLNESS: no other family members have no any major diseases like tuberculosis, ischemic heart diseases ,cancer ,asthma ,allergy ,etc.
SIBLING HISTORY: she is first child of her parents.
IMMUNISATION HISTORY: no any vaccine given to her.
1.General health –
Vital signs: Temperature -96 F
Respiration – by ventilator 20 breaths/min
Apical Pulse- 138 beats/min
Weight : 2.310 kg
Height : 48 cm
Head circumference : 32 cm
Chest circumference: 30cm
Posture : body flexed, hands tightly clenched,neck appear short because cheek rest on chest.
2 . Skin – color and sign of jaundice is to be noted. dehydration is present. milia is present across the bridge of nose.
3. Head : round , symmetry ,easily move left to right and down to up, greater than chest circumference. Anterior fontanel is 4-5 cm in diamond shape. 1-2 cm at birth triangle shape. slight pulsation and bulging is also present. Hair is smooth with fine texture. Hair distribution is also normal.
4. Face : symmetric movement of all facial features. Eyebrows and eye lashes present. Eye-ear at same level. Nostrils equal size.Facial skin – Smooth pink.
5. Ears – pinna is parallel to the outer and inner can thus of eyes. Both ear is symmetric. Responds to voice and sound
6. Eyes – Bruised and puffy eyelids. Blinking to be observed. Focusing on the line of vision to be noted.
7. Nose – Shape. Breathing normally through both nostrils with lips closed. Sneezing is noted.
8. Mouth – hard palate in domed shape. Uvulva midline with symmetric movement of soft palate. Tongue freely moving in all direction.
9. Neck – short , straight, creased with skin folds. Contraction of the shoulder and arm muscles
11. Chest – 2 nipples symmetric.breast tissue diameter is normal like 5 cm in diameter. Breast may have some enlargement. Symmetrical expansion of chest. transient breath sound is heard because of secretion present in respiratory track. Sometimes brief apnea is present . heart sound auscultate normal rate and rhythm without murmur.
12. Abdomen: cylindrical with some protrusion. Appears large in relation to pelvis. No protrison of umbilicus . two arteries and one vein is present.
13. Genitalia –Female – clitoris is covered with labia majora . Normal skin color. No vaginal tag. Vaginal discharge is not present. Buttocks are symmetric. Me conium pass 4 hrs after birth.
14. extremities and trunk- short and generally flexed, extremities moves symmetrically through range of motion but lack of extention. Arms and legs also equal in length. Palmer crease is also present. Legs shorter than arms. C- shaped spine.
15. Sleep – 12 to 16 hours in a day
16. Urine passing –12 hours after birth. One wet diaper every 8 hours on day 2. This will gradually increase to 6-8 wet diapers in 24 hours on day 5.
17. Stool – First stool within 4 hours
18. Reflexes- Moro’s, Routine, sucking ,palmer grasp, babinski reflex is present
SAMPLE PATIENT VALUE
Hemoglobin 19 mg/dl 12.3-15.3 mg/dl 3.7 moreRBC 5.3 million/cu 4.5-5.1 million/cu 0.2 more
Hematocrit 60.6% 35.9-44.6% 16% moreWBC 26500/cumm 4,400-11,000 15500 moreDifferential countNeutrophil 40% 50-70% 10%lessLymphocyte 55% 20-40% 15% moremonocytes 4% 2-6% Normal Eosinophils 1% 1-6% 5%Basophils 0% 0-2.5% 2.5%Platelet count 2,78,000/cumm 1,50,000-4,50,000 Normal
Renal function test Blood urea 38 mg/dl 15-45mg/dl NormalSerum creatinine 0.88 mg/dl 0.7-15 mg/dl Normal Liver function testBillirubin total 0.8 0.2-1.2 Normal direct - 0.0-0.5 - indirect - 0.0-0.2 -Serum alkaline phosphate
184 <500 less
S.G.P.T 39U/L 0-55U/L NormalProthrombin time 13sec 9.5-14.1 sec NormalINR 1.13Sec - -C-Reactive protein
2.4mg/dl <0.6mg/dl Positive
- Chest x-ray: pneumothorax is present.
Inj sulbacin 400kg I.V Inj Amikasin 30 mg i.v Inj Gardinal 40 mg i.v Inj meropenum 40 mg i.v Inj levoflox 2.0 mg I.V Inj fentanyl 2 mg i.v
15. NURSING DIAGNOSIS AND PROCESS:
Objective data: Newborn is in respiratory distress, bilateral advantageous breath sounds, with deep intercostal retractions and substernal retractions.
Impaired gas exchange related to inadequate surfactant levels; as evidenced by grunting, flaring, substernal and intercostal retractions
Neonate will maintain normal respiration by her own effort
- Administer oxygen.
- Monitor and document hourly.
-Auscultate lung sound every hourly.
- Maintain gastric decompression per oral gastric tube open to air, perform oral/nasal suctioning.
- Maintain temperature in normal range.
-Administered warmed and humidified oxygen at rate ordered .
- Monitor and document hourly FiO2 levels,pulse oximeter, and vital signs
- Auscultate lung fields hourly and assess respiratory effort hourly, grunting, flaring or retracting and activity. - Maintained gastric decompression per oral gastric tube open to air, perform oral/nasal suctioning and chest physiotherapy as ordered. - Maintain temperature in normal range and schedule nursing interventions to help newborn minimize stress, conserve energy, and reduce oxygen requirements.
The newborn was weaned to room air after 8 hours. clear breath sounds, 99-100% per pulse oximeter. while on room air, absence of tachypnea, grunting, flaring, retracting
ASESSMENT NURSING DIAGNOSIS
Objective data: Newborn is on radiant warmer with temperature
Ineffective thermoregulation related to low birth weight as evidenced by poor flexion and lack of subcutaneous fat stores
The new born will maintain thermal hemostasis.
- Provide neutral thermal environment per radiant warmer.
- Protect newborn from loss of body heat.
-Cover warmer bed over infant's chest and lower body.
- Monitor axillary temperature hourly and adjust settings on warmer.
-Warm and humidify oxygen being delivered to newborn
-Provide neutral thermal environment per radiant warmer with temperature probe secure and in anterior position to newborn. - Protect newborn from loss of body heat from conduction, convection, radiation, and evaporation. - Cover warmer bed over infant's chest and lower body with saran wrap to prevent insensible fluid loss and drafts.- Monitor axillary temperature hourly and adjust settings on warmer as needed to maintain temperature of 97.8 to 98.8 F. - Warm and humidify oxygen being delivered to newborn.
The radiant warmer was required for 18 hours and thereafter an incubator with neutral thermal environment based on her age and weight probided a warm, safe environment.
ASESSMENT NURSING DIAGNOSIS
Newborn is losing her weight
Altered nutrition less than body requirement related to respiratory distress; as evidenced by respiratory rate greater than 60 per minute, and NPO status.
The newborn will maintain adequate hydration, output, glucose levels
-Provide IV fluids, D10W for hydration and glucose.
-Assess need for parenteral nutrition.
-provide formula feeding.
- provide feedings through a nasogastric (NG) tube.
- Monitor glucose levels hourly until stable
-Provided IV fluids, D10W for hydration and glucose while newborn is under oxyhood.- Assessed need for parenteral nutrition if oxygen therapy is longer than 12 hours. - When respiratory status has stabilized begin feeding newborn D5W to assess tolerance to oral feedings. Begin formula feedings after two glucose water feedings. - If newborn does not have a strong sucking, gag, or swallow reflex or is at risk for aspiration, provided feedings through a nasogastric (NG) tube. - Monitored glucose levels hourly until stable, each four hours times two, then every eight hours while on IV fluids.
The newborn has increased weight after NPO status by proving feedings through a nasogastric (NG) tube.
-Behrman, “Killegman Jenson” Nelson Textbook of Pediatrics”, 11th
edition, Saunclers Publication, Philadelphia, 2008, Pp271-278
-Dorthy R. Marlow, et. at “Textbook of Pediatric Nursing”, 6th edition,
New Delhi Saunders Publication, 2006, Pp722-756
-Ghai O. P et al “Essential Pediatric”, 6th CBC Publisher and
distributors, New Delhi Pp 124-130
-Hocken Bery “Wong’s Nursing Care of Infants and Children”, 8th
edition, Mosby publication , USA, 2007 Pp 579-602
-Mcltosh Neil “Forfar & Arneils Textbook of Pediatrics” 7th edition,
Churchill livingstone Elsevier publication, Pp 645-652
-Niraja K.P.’Text book of growth and development” first
edition,Jaypee Brothers.New delhi, Pp 125-140
-Tambulwadker R.S.,”Paediatric nursing ” second
editon,vora medical publication,Mumbai, Pp 122-128
J G COLLEGE OF NURSING
SUBJECT: CHILD HEALTH NURSING
TOPIC : “CARE PLAN ON RESPIRATORY
SUBMITTED TO: SUBMITTED BY :
Prof. U.Ramya mam Ms Himali prajapati
JG College of nursing JG College of nursing
SUBMITTED ON:17/12/2010 ROLL NO: 10