Parent Newborn Nursing Case Study Tammy Bailes Mellanie

Parent Newborn Nursing Case Study Tammy Bailes Mellanie Hopkins Tiffany Kent Christen Miller

Mother’s Profile �L. S. �Age 24 �Reason for admission – delivery �Former ½ pack per day smoker �No alcohol or drug use �No prenatal classes

Medical History �History of depression �Cyst on ovary at age 14 �Arm surgery as child �Victim of domestic violence by parents �G 1 P 0 �EDD 1/31/09 �Weeks gestation 40. 5

Prenatal Lab Data Prenatal Test Norms Patient Results Analysis Type & Rh Rh+=Rhogam O+ No risk for development of permanent active immunity of Rh antigen. Hematocrit 34 -46 38. 1 No sign of anemia. Hemoglobin 12 -16 13. 2 No sign of anemia. VDRL Non reactive No sign of syphyllis. Rubella Immune Will not need vaccination. Urine C&S N/A Sickle Cell N/A

Labs Continued Prenatal Tests Norms Patient Results Analysis Chlamydia Gonorrhea Negative No infection. PAP test Normal WNL No sign of cancerous cells. Triple Screen N/A 1 Hour Glucose Screen 70 -139 mg/dl Patient could not tolerate Not determined.

Labor and Delivery Data �Vaginal delivery on 2/4/09 �Pain management via epidural �AROM 0848. Moderate amount of light meconium colored amniotic fluid. �Induction with Pitocin �Stage 1 – 29 hours 45 minutes �Stage 2 – 53 minutes �Stage 3 – 6 minutes �Total time 30 hours, 44 minutes

Mother’s Postpartum Assessment �Lung sounds clear �Bowel sounds present at all 4 quadrants �Breasts soft and nontender �Abdomen firm, FH -1 below �Lochia – moderate rubra �Pedal pulses +2 �Negative Homan’s sign in both extremities �Episiotomy midline and well approximated �BP, P &R WNL

Medications During Pregnancy �Folic Acid - Studies have shown that women who get 400 micrograms daily prior to conception and during early pregnancy reduce the risk that their baby will be born with a serious neural tube defect by up to 70%. �Flintstone's Multivitamin – Taken in place of prenatal vitamins due to GI upset. Prenatal vitamins are specially formulated to make up for any nutritional deficiencies in the mother's diet. While the supplements contain numerous vitamins and minerals, their folic acid, iron, and calcium content are especially important.

Medications During Labor � Pitocin – Triggers and strengthens contractions to induce or move labor along. Delivered IV starting with a small dose and gradually increased it until contractions are strong and frequent enough for the baby to be born. � Lactated Ringers – Used to start and maintain the infusion of Pitocin. This avoids risk of infusing a large dose of Pitocin as the line is begun and provides additional fluids while the solution is kept at a low infusion rate. � Epidural - Block the nerve impulses from the lower spinal segments resulting in decreased sensation in the lower half of the body.

Postpartum Lab Data Tests Norms Patient Results Analysis WBC 5, 000 -10, 000 mm 3 25, 000 -30, 000 mm 3 PP 20. 7 H Increased neutrophils from a physiologic response to stress. RBC 4. 2 -5. 4 2. 95 L Loss of blood, anemia Hgb 12 -16 8. 2 L Anemia Hct 38 -47 24. 8 L Loss of blood, anemia

Nutritional Assessment �Prepregnant weight 110 lbs, 40 pounds total weight gain during pregnancy. �Will bottle feed and receive WIC assistance. �Patient does the grocery shopping and cooks with no special dietary restrictions. �Very little physical activity.

Newborn Data �Female �Gestational age 40. 5 weeks �Apgar score � 1 minute=9 � 5 minutes=9 �Birth weight 6 pounds 11 ounces � 19” in length �Bottle feeding �Mother did not attend prenatal classes

Newborn Assessment �Temperature 97. 8 �Pulse 124 �Respirations 32 �Skin pink �Lung sounds clear �Fontanels midline �Sucking, grasp, Babinski, rooting reflexes present

Newborn Medications �Vitamin K – Given prophylactically IM on the day of birth to prevent hemorrhage which can occur because of low prothrombin levels the first few days of life. �Erythromycin Ophthalmic Ointment – prophylactic treatment of opthlamia neonatorum required by law

Postpartum Medications �Motrin-600 mg PO q 8 h– for mild to moderate pain. �Tylenol 3 – 1 -2 tablets PO q 4 h PRN for moderate pain. �Ferrous sulfate – Iron supplement for anemia. L. S. postpartum hemoglobin at 8. 2 �TDAP – IM tetanus, diphtheria, acellular pertussis vaccine

Care Plan for Mother

Pain R/T episiotomy AEB 6 on pain scale �I - Assess level of pain. �R: to determine the interventions you will use. �I - Provide optimal pain relief with prescribed analgesics (Low on pain scale Motrin q 6 hr, or high on pain scale Tylenol #3 prn). �R: Relieving pain allows for promotion of activity. �I - Use of hot or cold applications. �R: Cold can reduce inflammation that causes pain and heat (sitz bath) promotes healing in the affected area. �I - Teach pt. to use relaxation techniques. �R: The use of non-invasive pain relief measures can enhance therapeutic effects of pain relief medications.

Risk for infection R/T surgical incision. � I - Assess nutritional status to provide adequate protein and caloric intake for healing. � R: To repair tissue, the body needs increased protein and carbohydrate intake and adequate hydration for vascular transport of oxygen and wastes. � I – Monitor vital signs q 4 h. � R: Provides a baseline that allows quick recognition of deviations in subsequent measurements. � I – Monitor episiotomy at least q 4 h for redness, drainage, oozing, hematoma, or loss of approximation. � R: Provides clinical data needed to quickly recognize the presence of infection. � I – During postpartum period, monitor fundal height at least q 4 h for 48 h. � R: Provides database necessary to screen for infection

Risk for ineffective coping R/T history of depression �I – Schedule in home follow-up to assess status of depression. �R: Helps to identify issues and can lead to problem solving. �I – Teach pt. self monitoring techniques and when to seek help. �R: Teaches them how to recognize and know when pt. needs more intensive help. �I – Reassure pt. that depression is common post-partum. �R: Pt. with chronic mental illness must give up role of being sick for being different. �I – Teach pt. use of cognitive therapy technique. �R: Cognitive interventions help person control his/her life with replacing automatic negative thoughts with positive thoughts.

Risk for impaired infant attachment related to lack of knowledge. �I – Encourage mother to talk about her feelings regarding being a new parent. �R: Opens line of communication so mother will feel comfortable and be honest about her feelings/fears. �I – Observe both parents’ interactions with infant. �R: Makes sure the bonding is appropriate, ensures infants safety. �I – Ask mother specific questions about taking care of her infant at home. �R: Nurse can decide what exactly mother needs help or guidance with. �I – Refer to programs in the community that help new parents. �R: New mother will have somewhere to go if she has questions or needs help.

Nursing Diagnoses for Newborn �Risk for infection related to umbilical cord healing. �Acute pain related to vitamin K injection. �Risk for impaired tissue integrity related to thin epidermis. �Risk for imbalanced body temperature related to less adipose tissue for insulation with newborns.