Diagnostic Procedure / Laboratory

Complete Blood Count (CBC) The complete blood count (CBC) test measures several components of blood to assess the patient for various disorders. The CBC can also test for loss of blood, abnormalities in the production or destruction of blood cells, acute and chronic infections, allergies, and problems with blood clotting. NORMAL VALUES ACTUAL FINDINGS ANALYSIS NURSING /INTERPRETATION OF RESPONSIBILITIES March 17, 2013 March 21, 2013 THE RESULTS (WHITE BLOOD CELLS) 5.0-10.0 H 109/l 9.1 H 109/l 13.8H 109/l DEVIATION FROM Before: WBC NORMAL. Increased in WBC Explain to the SO the indicates presence of infection. (LYMPHOCYTES) %LYM 17.0-48.0 H % 40.9 H % 28.0 H % NORMAL indication/purpose of (MONOCYTES) %MON 4.0-10.0 % 5.4 % 12.8 % DEVIATION FROM the test, that this test NORMAL. Increased in detects presence of monocytes also indicates presence of infection. infection and other (GRANULOCYTES) %GRA 43.0-76.0 % 45.2 % 59.2 % NORMAL abnormal conditions of (RED BLOOD CELLS) RBC 3.8-5.8 1012/l 4.74 1012/l 4.42 1012/l NORMAL (HEMOGLOBIN) HGB 110-165 H g/l 172 H g/l 173 H g/l DEVIATION FROM the blood NORMAL. Increased in Explain to the SO the hemoglobin indicates dehydration. procedure that the test (HEMATOCRIT)HCT 0.350-0.500 H l/l 0.509 H l/l 0.477H l/l DEVIATION FROM requires blood sample, NORMAL. Decreased in hematocrit indicates and who will perform nutritional deficiency. it. (MEAN CORPUSCULAR 80-97 H 107 H 108 H DEVIATION FROM VOLUME) MCV NORMAL. Increased in MCV Tell the SO that the indicates nutritional baby may feel deficiency. (MEAN CORPUSCULAR 26.5-35.5 H pg 36.3 H pg 39.1 H pg DEVIATION FROM discomfort from the HEMOGLOBIN) MCH NORMAL. Increased in MCH

indicates nutritional deficiency.

needle puncture and pressure on the tourniquet. That the baby may struggle and cry. During Ensure clients comfort. After If hematoma develops at the site, apply warm soaks. Ensure sub dermal bleeding has stopped before removing pressure. If hematoma is large monitor pulses distal to the site. Document the procedure and attach the result in the

patients chart. (MEAN CORPUSCULAR 315-350 H g/l HEMOGLOBIN CONCENTRATION) MCHC (RED CELL DISTRIBUTION 10.0-15.0 H % WIDTH) RDW 150-390 109/l 338 H g/l 362 H g/l DEVIATION FROM NORMAL. Increased in MCHC indicates nutritional deficiency. DEVIATION FROM NORMAL. Increased in RDW indicates nutritional deficiency. DEVIATION FROM NORMAL. Decreased in platelets indicate presence of infection. NORMAL NORMAL DEVIATION FROM NORMAL. Decreased in PDW indicate presence of infection.

18.2 H %

18.1 H %

(PLATELET) PLT

153 109/l

126 109/l

(MEAN PLATELET VOLUME) MPV (PLATELETCRIT) PCT (PLATELET DISTRIBUTION WIDTH) PDW

6.5-11.5 fl 0.100-0.500 10-2/l 10.0-18.0 %

8.4 fl 0.128 10-2/l 11.7 %

9.0 fl 0.113 10-2/l 5.9 %

Serum Electrolytes It is used to identify an electrolyte or acid-base imbalance and to monitor the effect of treatment on a known imbalance that is affecting bodily organ function. Since electrolyte and acid-base imbalances can be present with a wide variety of acute and chronic illnesses, the electrolyte panel is frequently ordered for hospitalized patients and those who come to the emergency room. NORMAL VALUES ACTUAL FINDINGS March 22, 2013 Serum Sodium 137-145 mmol/L 154 mmol/L March 23, 2013 154 mmol/L ANALYSIS /INTERPRETATION OF THE RESULTS DEVIATION FROM NORMAL. Increased in Serum Sodium level indicates dehydration. DEVIATION FROM NORMAL. Increased in Serum potassum level indicates dehydration. NURSING RESPONSIBILITIES Before: Explain to the SO the indication/purpose of the test, that this test detects presence of infection and other abnormal conditions of the blood Explain to the SO the procedure that the test requires blood sample, and who will perform it. Tell the SO that the baby may feel

Serum Potassium

3.6-5.0 mmol/L

6.9 mmol/L

6.9 mmol/L

discomfort from the needle puncture and pressure on the tourniquet. That the baby may struggle and cry. During Ensure clients comfort. After If hematoma develops at the site, apply warm soaks. Ensure sub dermal bleeding has stopped before removing pressure. If hematoma is large monitor pulses distal to the site. Document the procedure and attach

the result in the patients chart.

Bilirubin Level The bilirubin test is used to diagnose conditions that cause increased destruction of red blood cells, such as hemolytic anemia or hemolytic disease of the newborn. Help make decisions about whether newborn babies with neonatal jaundice need treatment. These babies may need treatment with special lights, called phototherapy. In rare cases, blood transfusions may be needed. NORMAL VALUES ACTUAL FINDINGS March 23, 2013 Bilirubin total Up to 1.1 umol/L 21.53 umol/L ANALYSIS /INTERPRETATION OF THE RESULTS DEVIATION FROM NORMAL. Increased in level of Bilirubin indicates jaundice. DEVIATION FROM NORMAL. Increased in level of Bilirubin indicates jaundice. DEVIATION FROM NORMAL. Increased in level of Bilirubin indicates jaundice. NURSING RESPONSIBILITIES Before: Explain to the SO the indication/purpose of the test, that this test detects presence of infection and other abnormal conditions of the blood Explain to the SO the procedure that the test requires blood sample, and who will perform it.

Bilirubin Indirect

Up to 0.85 umol/L

19.13 umol/L

Bilirubin Direct

Up to 2.4 umol/L

2.4 umol/L

Tell the SO that the baby may feel discomfort from the needle puncture and pressure on the tourniquet. That the baby may struggle and cry.

During Ensure clients comfort. After If hematoma develops at the site, apply warm soaks. Ensure sub dermal bleeding has stopped before removing pressure. If hematoma is large monitor pulses distal to the site.

Document the procedure and attach the result in the patients chart.

THE PATIENT AND HIS CARE A. MEDICAL MANAGEMENT a. IVT, Blood transfusion, Nebulization, Total parenteral nutrition, NGT, Oxygen therapy etc.

Medical management

O2 inhalation

Date Ordered Date Take/Given Date Change/Discontinu e Date Ordered 5/17/13

Route of Administratio n Dosage Frequency Via hood regulated at 8 Lmp

General description Inhalation of oxygen aimed at restoring toward normal any pathophysiolo gic alterations of gas exchange in the cardiopulmon

Indication

Clients Response

Nursing Considerations

Date Given 5/17/13 @ 11:00

Inhalation of oxygen aimed at restoring toward normal any pathophysiologic alterations of gas exchange in the cardiopulmonary system.

Patient responds to treatment without any risk manifested

Before: Check for doctors order for the route of administration, and the regulation Check the clients respiration and also its rate. Avoid the use of volatile, flammable materials such as oils,

a.m.

ary system, as by the use of a respirator, nasal catheter, tent, chamber, or mask. (From Dorland, 27th ed& Stedman, 25th ed). An oxygen hood is used for babies who can breathe on their own but still need extra oxygen. A hood is a plastic dome or box with warm, moist oxygen inside. The hood is placed over the baby's head.

greases, alcohol, ether, and acetone, near clients receiving oxygen. During: Make sure that the hood is in place Monitor the client, the gas should not be allowed to blow directly into the infants face and the hood should not rub against the infants neck, chin or shoulder. Inspect the facial skin frequently for dampness or chafing and treat as needed Inspect the equipment on regular basis. Check the liter flow, the water in the humidifier and make sure precautions are followed. After: Document date and time given and date discontinued.

Medical management

D10W

Date Ordered Date Take/Given Date Change/Discontinu e Date Ordered 5/17/13

Route of Administratio n Dosage Frequency 100 cc Via umbilical catheterization

General description

Indication

Clients Response

Nursing Considerations

Date Given 5/17/13 @ 11:00 a.m. Regulated at 5 microgtts/min

This medication is a solution given by vein (through an IV). It is used to supply water and calories to the body. It is also used as a mixing solution (diluent) for other IV medications. Dextrose is a natural sugar found in the body and serves as a major energy source. When used as an energy source, dextrose allows the body to preserve its muscle mass.

IV solutions containing dextrose are indicated for parenteral replenishment of fluid and minimal carbohydrate calories as required by the clinical condition of the patient. It is also use as a mixing solution for other IV medication

Patient responds to treatment effectively without any side effects

Before: Check for doctors order for IV insertion, its drop factor and amount ordered Check for the expiration date Arrange for testing the amount of serum sodium and glucose Check the weight of the client During: Make sure that the cannula is in place. Assess the site for bleeding and swelling. Make sure that IV infusion is in correct regulation. Secure the tube, make sure that it is not dislodging Monitor the clients condition.

After: Document date and time given and date discontinued. Monitor if there are any complications and report it immediately to the pediatrician.

Medical management

D5IMB

Date Ordered Date Take/Given Date Change/Discontinu e 5/13/13 @ 11:55 a.m.

Route of Administratio n Dosage Frequency 100 cc Thru soluset Regulated at 7 microgtts/min

General description Also known as Balanced Multiple Maintenance solution with 5% dextrose. It is a hypertonic solution. It contains a high concentration of solute relative to another

Indication

Clients Response

Nursing Considerations

Date given: 5/13/13

Discontinued

Indicated for slow administration essential to prevent overload, water intoxication and severe sodium depletion. It is usually given to patients in hospitals that could potentially become ill through high

Patient responds to treatment without any allergic reaction.

Before: Check for doctors order for IV insertion, its drop factor and amount ordered Dont administer unless solution is clear and container is undamaged During: Make sure that the cannula is in place. Assess the site for bleeding and

5/16/13

solution. When a cell is placed in a hypertonic solution with water diffuses out of the cell, causing the cell to shrivel.

sodium levels.

swelling. Make sure that IV infusion is in correct regulation. Secure the tube, make sure that it is not dislodging Monitor the clients condition. Monitor for the I&O. After: Document date and time given and date discontinued. Monitor if there are any complications and report it immediately to the paediatrician.

B. Drugs

Generic name / Classification Piperacillin sodiumTozabactam sodium Antibiotic, penicillin

Date ordered/ Date given Ordered: 5/17/13 @ 10:30 a.m. Given: 5/17/13 @ 6:00

Dosage/ Route and Frequency of administration 130 mg

Action

Clients Response

Nursing Responsibilities

TIV

A combination of piperacillin sodium and tazobactam sodium, a betalactase inhibitor. Tazobactam inhibits

Client experienced no side effects and allergies

Before: Check the doctors order. Check the medication name while getting it from the medicine drawer, shelf or refrigerator, before calculating

p.m. 5/18/13 @ 6:00 a.m. 5/19/13 @ 6:00 a.m. and 6:00 p.m. 5/20/13 @ 6:00 a.m. and 6:00 p.m. 5/21/13 @6:00 a.m. and 6:00 p.m. 5/22/13 @6:00 a.m. and 6:00 p.m. 5/23/13 @6:00 a.m. and 6:00 p.m. 5/24/13 @ 6:00 a.m. and 6:00 p.m. 5/25/13 @ 6:00 a.m. and 6:00 p.m. 5/26/13 @ 6:00 a.m. and 6:00 p.m. 5/27/13 @ 6:00 a.m. and 6:00 p.m. 5/248/13 @ 6:00 a.m. and 6:00 p.m.

beta-lactamases, thus ensuring the activity of piperacillin against beta lactamaseproducing microorganisms. Thus, tazobactam broadens the antibiotic spectrum of piperacillin to those bacteria normally resistant to it. Inhibits bacterial cell wall mucopeptide synthesis. It is highly active

the dosage and before administering it to the client. Check the expiration date Calculate the dose to be given accurately Prepare the drug by reconstituting it with the right amount of sterile water aseptically. Explain the drug to the significant others of the patient During: Give medication on time and according to the frequency Identify the client by checking the identification tag. Wipe the y-port with alcohol swab to remove microorganisms Administer the medication aseptically and slowly After: Monitor the client for any side effects such as dyspnea,nausea and vomiting, rashes, diarrhea, constipation. Check for the respiration and rate of the patient Report immediately to the physician if side effects occur. Store the medication in the refrigerator Document the time the drug was given, name of the drug and signature of the one who gave

and prepared the drug.

Generic name / Classification Gentamicin Antibiotics, aminoglycosides

Date ordered/ Date given Ordered: 5/17/13 @ 10:30 a.m. Given: 5/17/13 @ 6:00 p.m. 5/18/13 @ 12:00 p.m. 5/19/13 @ 12:00 p.m. 5/20/13 @ 12:00 p.m. 5/21/13 @ 12:00 p.m. 5/22/13 @12:00 p.m. 5/23/13 @ 12:00 p.m. 5/24/13 @ 12:00 p.m. 5/25/13 @ 12:00 p.m. 5/26/13 @ 12:00 p.m.

Dosage/ Route and Frequency of administration 6 mg

Action/Use

Clients Response Clients response to treatment has improved, no further infection detected No side effects and allergies noted

Nursing Responsibilities

TIV

Broad spectrum antibiotics believed to inhibit protein synthesis by binding irreversibly to ribosomes thereby interfering with an initiation complex between messenger RNA and the 30s subuinits. This leads to production of non-functional proteins Indicated for infections which include bacterial neonatal sepsis, bacterial septicaemia and serious infection of the skin

Before: Check the doctors order. Check the medication name while getting it from the medicine drawer, shelf or refrigerator, before calculating the dosage and before administering it to the client. Check the expiration date Calculate the dose to be given accurately Prepare the drug by reconstituting it with the right amount of sterile water aseptically. Explain the drug to the significant others of the patient During: Give medication on time and according to the frequency Identify the client by checking the identification tag. Wipe the y-port with alcohol swab to remove microorganisms Administer the medication

5/27/13 @ 12:00 p.m. 5/28/13 @ 12:00 p.m.

aseptically and slowly After: Closely monitor the client for any side effects such as dyspnea,nausea and vomiting, rashes, diarrhea, constipation, numbness, muscle weakness Closely and strictly monitor for any toxicity in the kidneys and also for hearing loss because it may cause nephrotoxicity and severe hearing loss. Check for the respiration and vital signs of the patient Report immediately to the physician if side effects occur. Store the medication in the refrigerator Document the time the drug was given, name of the drug and signature of the one who gave and prepared the drug.

c. Diet

Type of Diet

Date ordered, date taken/given,

General description

Indications /purposes

Client response to the diet

Nursing Considerations

date change, date discontinued Breastfeeding May 17,2013 with Strict aspiration Precaution Breastfeeding is defined as the extent of understanding conveyed about lactation and nourishment of an infant through breastfeeding.(Johnson, Maas, Moorhead, 2000) It provides numerous health benefits to both mother and the infant. The immunologic properties of breast milk play a major role in preventing disorders such as necrotizing enterocolitis and sepsis. good suck noted Before: Check for doctors order Explain to the clients SO the purpose of breastfeeding Instruct the mother of the client to cleanse first her breast Provide privacy and place woman in comfortable sitting position. During: Make sure that patients mother followed doctors order. Strictly reinforce aspiration precaution After: Document date and time Reinforce to burp after feeding

Dropper Feeding

May 19,2013

Dropper feeding is defined as Preemie babies who providing milk through the have trouble with use of a dropper. sucking and swallowing may not be able to breastfeed or use a bottle to start with. An eye dropper or a syringe (like you use for medicines) can be used and often have measurement

good suck observed

Before: Identify the client. Check for doctors order. Explain purpose of dropper feeding Instruct to the mother of the client that it will alternate with breastfeeding as ordered Instruct the amount to be given to the client as ordered Strictly reinforce aspiration precaution During: Make sure that patient followed doctors order After: Document date and time. Reinforce to burp after feeding

markings. Knowing how much has been eaten can help with over or under feeding your two infants