Newborn Careplan 9-15-2011

8/3/2019 Newborn Careplan 9-15-2011

http://slidepdf.com/reader/full/newborn-careplan-9-15-2011 1/17

PATRICK HENRY COMMUNITY COLLEGE

CARE PLAN FOR

NURSING 118: MATERNAL/CHILD NURSING

NEWBORN

Student Name: Brittany Wood Instructor Use Only:

Satisfactory_____ Date of Clinical: 9-15-2011 Unsatisfactory___

Date Submitted: 9-19-2011 Date___________ Instructor______________________________

Student Review Signature_________________

Demographic Data:

Date of Delivery: September 13, 2011 Time of Delivery: 1322 PM

Sex: Male Age: 2 days old Gestational Age: 40 weeks 3 days

Gestational age by Dubowitz assessment: 38 weeks____________________________

Birth weight: Grams: 3917 Pounds: 8 lbs Ounces: 10.2 oz

Weight today: Grams: 3672 Pounds: 8 lbs Ounces: 1 oz

Is newborn small, large, or appropriate weight for gestational age? Large (LGA)

Apgar Scores: 1 minute: 8 5 minutes: 9

Fetal complications: LGA, and Jaundice

Medications received by mother during labor and delivery: Nubain 20 milligrams

Resuscitative measures: N/A

Blood Type: Maternal: B- Newborn: B+ Coombs: Not necessary for newborn

Breast or Bottle Feeding: Breast feeding

1



MEDICATIONS GIVEN SINCE DELIVERY

MEDICATION/DOSAGEROUTE/FREQUENCY

Drug: Vitamin K

Dose: 0.5 mg

Route: injection IM

Site: Left Thigh

RATIONALE

o Vitamin K is needed for

blood clotting.

o Babies are born with very

small amounts of vitaminK in their bodies. This puts

them at risk of hemorrhagicdisease of the newborn

(HDN).

o As a preventive measure,

babies are routinely givenvitamin K injections at

birth.

NURSING RESPONSIBILITIES∆ Monitor for frank and occult

bleeding.∆ Monitor pulse and blood pressure

frequently; notify physician

immediately if symptoms of internal bleeding or hypovolemic shock develop.

∆ Newborns should be observed for

vitamin K deficiency.

∆ The incidence of vitamin K

deficiency is higher in breast-fed

infants.∆ In infants (particularly premature

babies), excessive doses of vitamin

K during the first few days of life

may cause Hyperbilirubinemia; thisin turn may result in severe

hemolytic anemia, hemoglobinuria,

and kernicterus, leading to braindamage or even death.

Drug: Hepatitis B

MERCK/Recombivax HB

Dosage: 5mcg

Route: Injection IM

o To promote active

immunity in individuals at

high risk of potentialexposure to hepatitis B

virus or HBsAg-positive

materials.

o Has been usedsimultaneously with

hepatitis B immune

globulin (H-BIG) for post-exposure prophylaxis in

selected patients and in

infants born to HBsAg-

positive mothers.

∆ In neonates inject the vaccine into theanterolateral thigh, avoiding blood

vessels and nerves.

∆ Carefully aspirate to preventinadvertent intravascular injection.

∆ Have epinephrine immediately

available to treat anaphylaxis.∆ Shake vial well before

withdrawing dose to assure uniform

suspension.

∆ Monitor for adverse reactions:• Mild local tenderness at injection

site• Local inflammatory reaction

(swelling, heat, redness, pain)

• Fever

• Malaise

• Fatigue• Nausea

• Vomiting

• Diarrhea

• Rash

• Urticaria

• Pruritus

2



Erythromycin or tetracycline

Ophthalmic Ointment

o Part of the routine care of

the newborn is to give prophylactic eye treatment

against gonorrhea

conjunctivitis or opthalmia

neonatorum.

o Neisseria gonorrhea, the

causative agent, may be passed on the fetus from

the vaginal canal duringdelivery

∆ Apply over lower lids of both

eyes

∆ Manipulate eyelids to spread

medication over the eyes

∆ Monitor for irritation

∆ Provide mother with informationregarding purpose and information of

the administration of ointment.

3



MEDICAL PROCEDURES

TREATMENT

Circumcision:

The procedure was to be

completed after I had leftthe clinical site.

Was to be performed before

discharge 9-15-2011

RATIONALE

o Circumcision is the

removal of the foreskin, which

is the skin that covers the tip of

the penis.

o In the United States, it is

often done before a new baby

leaves the hospital.

o There are medical benefits

and risks to circumcision.

o Possible benefits include a

lower risk of urinary tract

infections, penile cancer andsexually transmitted diseases.

o The risks include pain and

a low risk of bleeding or

infection (these risks are higher

for older babies, boys and men)

NURSING

RESPONSIBILITIES

∆ Provide parents withsufficient information to make

an informed choice.

∆ Promote comfort and

healing.

∆ Identify and minimize postoperative complications.

∆ Instruct parent(s) in proper

care of circumcised infant.

4



NB Lab Screening:

∆ 9-13-2011

Age at which collection was

obtained: 32.9 hours old

∆ 9-13-2011

- Cord Blood PH: 7.36- ABO/RH ABO: B pos

∆ 9-14-2011

- TOT Billirubin: 8.8 H

- DIR Billirubin: 0.3 H

∆ 9-15-2011

- TOT Billirubin: 9.4 H

∆ 9-13-2011 Glucose:- Birth: 67 mg/dL LOW

- 2nd: 69 mg/dL LOW

- 3rd: 68 mg/dL LOW

o Every infant born in the United

States is screened shortly after

birth for a number of genetic

disorders.

o Serious problems, including

mental retardation and death,

can be prevented if the

disorders are discovered earlythrough newborn screening.

Total Bilirubin levels in

newborns up to 7 das old:

Normal Glucose Level:

Newborn: 80-90 mg/dL

Glucose checks reveal LOW bloodsugar

Persistently low glucose levels

increase the risk of hypoglycemiain the newborn!

∆ The skin of the heel is first

cleaned with alcohol

∆ Puncture the heel with a

small sterile lancet.

∆ Collect several drops of

blood in a small tube.

∆ When enough blood has

been collected, place a gauze pad or cotton ball over the puncture site. Pressure is

maintained on the puncture site

briefly.

∆ Apply small bandage.

∆ Preventive measures as

frequent feedings during the first6 to 12 hours of life to increase

GI motility have little

justification. Infants with mild jaundice require no treatment,

only observation. Phototherapy

is the usual treatment for severe

or increasinghyperbilirubinemia.

Early feeding:Encourage the mother to feed

frequently, especially if the baby is

sleepy or not keen.

Promote skin-to-skin contact:

This encourages breastfeeding; italso keeps your baby warm, which

lowers the risk of hypoglycemia.

Recheck blood glucose after

interventions:

Should always be first priority to

determine if interventions weresuccessful.

Once glucose levels stabilize work with the mother to form a routine

feeding schedule

5

AgePremature

baby

Full-term

baby

< 24

hour

s

< 8.0

mg/dL or <137

mmol/L

< 6.0

mg/dL or <103

mmol/L

< 48

hour

s

< 12.0

mg/dL or <

205

mmol/L

< 10.0

mg/dL or <

170

mmol/L

3 to

5

days

< 15.0

mg/dL or <

256

mmol/L

< 12.0

mg/dL or <

205

mmol/L

7

days

< 15.0

mg/dL or <

256

mmol/L

< 10.0

mg/dL or <

170

mmol/L



Coombs Screening if

indicated:

∆ Not indicated for newborn

patient

The test is looking for "foreign"

antibodies that are already adheredto the infant's RBC’s, a potential

cause of hemolysis.

This is referred to as antibody-mediated hemolysis.

The two most commonlyrecognized forms of antibody-

mediated hemolysis in newborns

are Rh incompatibility and ABOincompatibility.

6



NURSING DIAGNOSES

E v a l u a t i o n

7



N u r s i n g

I n

t e r v e n t i o n s

∆

I m m e d i a t e l y a f t e r b i r t h d r y t h

e i n f a n t s t i m u l a t i n g c i r c u l a t i o n t h r o u g h o u t t h e b o d y .

∆

P r o v i d e n e u t r a l t h e r m a l e n

v i r o n m e n t p e r r a d i a n t w a r m e r .

p o r a t i o n .

8



S u p p o r t i v e

D a t a

m a d a p t a t i o n t o e x t r a - u t e r i n e l i f e . N e w

b o r n s l o s e b o d y h e a t , a n d l o s e i t r a p i d l y , 4 w a y s b e c a u s e t h e i r n e u r o l o g i c a l s y s t e m s a r e n o t f u l l y d e v e l o p e d a t b i r t h :

9



N u r s i n g

D i a g n o s i s

R i s k f o r I n e f f e c t i v

e T h e r m o r e g u l a t i o n R / T i m m

a t u r e c o m p e n s a t i o n f o r c h a n g

e s i n e n v i r o n m e n t a l

t e m p e r a t u r e .

G o a l

N e w b o r n w

i l l d e m o n s t r a t e e f f e c t i v e t h e r m o r e g u l a t i o n A E B :

M a i n t a i n i n g a t e m p e r a t u r e o f 9 8 . 5 F a h r e n h e i t .

10



E v a l u a t i o n

G o a l M e t A E B :

I n f a n t d i s p

l a y s n o e v i d e n c e o f e y e i r r i t a t i o n .

N o s y m p

t o m s o f d e h y d r a t i o n w e r e n o t e d

u p o n a s s e s s m e n t .

i n e d w

i t h i n n o r m a l l i m i t s .

11



N u r s i n g

I n

t e r v e n t i o n s

S h i e l d i n f a n t ' s e y e s , m a k e c e r t a i n t h a t l i d s a r e c l o s e d b e f o r e a p p l y i n g s h i e l d t o p r e v e n t c o r n e a l i r r i t a t i o n

C h e c k e y e s e a c h s h i f t f o r d r a i n a g e o

r i r r i t a t i o n

P l a c e i n f a n t n u d e u n d e r

l i g h t f o r m a x i m u m s k i n e x p o s u

r e

t , t o i n c r e a s e b o d y s u r f a c e e x p o s u r e

a x i l l a

r y t e m p e r a t u r e

12



S u p p o r t i v e

D a t a

N e w b o r n l a b s r e v e a l e d h i g h

l e v e l s o f b i l l i r u b i n :

9 / 1 4 / 1 1 :

-

8 . 8 M G / D L H I G H

-

0 . 3 M G / D L H I

G H

H I G H I N

T E R M E D I A T E

9 / 1 5 / 1 1 :

-

. 4 M G

/ D L H I G H

13



N u r s i n g

D i a g n o s i s

R i s k f

o r i n j u r y r / t t h e r a p e u t i c t r e a t m e n t : P h o t o t h e r a p y

G o a l

I n f a n t r e m a i n

f r e e o f i n j u r y A E B :

N o e v i d e

n c e o f e y e i r r i t a t i o n , d e h y d r a t i o

n , t e m p e r a t u r e i n s t a b i l i t y , o r s k i n b r e a k d o w n .

14



E v a l u a t i o n

N u r s i n

g I n t e r v e n t i o n s

S

u p p o r t i v e

D a t a

15



N u r s i n g

D i a g n o s i s

R i s k f

o r h y p o g l y c e m i a r / t

L a r g e G e s t a t i o n a l A g e

G o a l

E v a l u a t i o n

N u r s i n g

I n t e r v

e n t i o n s

16



S u p p o r t i v e

D a t a

N u r s i n g

D i a g n o s i s

G o a l

17

Newborn Careplan 9-15-2011

Documents

Transcript of Newborn Careplan 9-15-2011