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Student initials: RMS

Date(s) of care: 05/31/08


Patient Information
Pertinent Medical History: Baby L was born 05/28/08 @ 11:18. Delivery CS for breech. Initial Assessment: weight was 6 lb, 5 oz.
(@0015, 05/31) length- 18.25” HC- 13.25”T-98.1F, resp-54; HR-66. Baby active; color is pink with olive undertones, good cry,
head normocephalic,fontanelles and sutures WNL.Milia present across nose. Hair is soft, black and sparse. Eyebrows and lashes
present, eyes and ears level, nostrils equal, no flaring observed. Sucking pads present. Palate intact, good suck reflex. Eyes
bright dark brown, + blink reflex, baby is responsive to sound and movement. No drooping or paralysis noted in face. Scelera
bluish-white. Ears are symmetrical, well-formed. No lesions noted. Clavicles straight and intact. BL lung expansion, Lungs clear
BL, nipples symmetric, flat. HR regular, no murmurs or thrills noted. Abdomen protruding, umbilical cord dry, no bleeding. Active
bowel sounds x 4 quad. No inguinal bulges, femoral pulses +1/4. Genitals symmetrical; pubis dark brown and engorged, scant
smegma present within labia. Buttocks symmetric, anus patent, no dimpling at coccyx. Symmetric buttock creases. All reflexes
charted as present. Apgar 8/9.
Occupation: newborn baby
Family History: FOC not present, great-grandmother has band.
Educational Level: none
Religion: none; mother is Baptist
Medications: none
Socio-cultural considerations: family is of low socioeconomic status; may need referrals to outside agencies
ALLERGIES: NKA
Current lab findings: blood Type B+
DNR status: full CPR
Current diagnostic findings: normal, healthy newborn
Assessment Nursing Diagnosis Goals & Expected Nursing Interventions Rationale for interventions Evaluation Evaluation
(Supporting data) (NANDA diagnostic Outcomes (Strategies or actions for care) (Include source and page numbers) (Client’s
statement) (Realistic, timed, response to
measurable) nursing actions
& progress
toward
achieving
goals &
outcomes)
Subjective: Baby is Assess infant’s temp each hour Infants lack mature thermoregulation.
calm, soothes easily, Risk for imbalanced Infant will maintain its Temps too high or too low can disrupt Goal Met:
does not appear body temperature r/t body temperature acid-base balance, causing seizures or Baby L’s
uncomfortable between 97.0 and shock. temp.
extreme of age
(newborn status) 99.0F for entire shift If temp is above 101F, take remains
Infants are at risk for febrile seizures r/t
measures to bring temp to normal WNL for
immature thermoregulation and must
range: be safeguarded against further entire shift
o Administer antipyretics as sequelae.
ordered
o Monitor and document Signs of neonatal seizures include:
Objective: Baby L’s related symptoms with
axilla temp: 98.1 F;
skin warm and dry
specific regard to febrile • Repetitive sucking
seizures • Repeated extending of the tongue
• Continuous chewing
• Continuous drooling
• Long pauses in breathing (apnea)
• Rapid eye movements
• Blinking/fluttering of eyelids
• Fixation of gaze to one side
• Body aligned to one side
• Pedaling/stepping movements of
legs
• Paddling/rowing movements of
arms
• Rapid muscle jerks

If temp is < 97.0F, take measures to Young infants cannot initiate


bring temp to normal range: compensatory regulation of
o place infant temperature and can become septic at
body temps below 97.0F
under warmer
Infants can become dehydrated under
warmer if not carefully monitored.
o or on mother’s
chest under
blanket
Cox’s Clinical Applications of Nursing Diagnosis; pg.141
Cox’s; pg.141
http://www.epilepsyfoundation.org/infants/neonatalonset.html

Assessment Nursing Diagnosis Goals & Expected Nursing Interventions Rationale for interventions Evaluation Evaluation
(Supporting data) (NANDA diagnostic statement) Outcomes (Strategies or actions for care) (Include source and page numbers) (Client’s response to
(Realistic, timed, nursing actions
measurable) & progress toward
achieving goals
& outcomes)
Subjective:
MOC states “I have no milk Ineffective Assess a feeding for proper Collect baseline data Baby L was able
because I had a c-section”; Baby will feed four technique to consume 20mL
MOC is using S&S to breastfeeding r/t times during shift, during four
supplement feedings. maternal breast supplementing with feedings
Determine effect of altered Maternal-infant response
anomaly AEB need for 20 mL of formula breastfeeding pattern on mother provides important
supplemental feedings per feed and infant by spending 30 information in determining
Objective:
and no observable minutes talking with mother. how serious the
maternal milk Observe mother-infant breastfeeding issue is. This
production interactions and maternal will dictate how to approach
feelings expressed. the problem and promote
Baby L is consuming 20-30 realistic follow-up.1
mL of formula per feeding; Measure I/Os
MOC’s breasts are very
tubular in shape, very little
mammary tissue present;
cannot express milk with
pump. Baby’s weight has
remained constant since birth
(6 lb, 5 oz)

Assessment Nursing Diagnosis Goals & Expected Nursing Interventions Rationale for interventions Evaluation Evaluation
(Supporting data) (NANDA diagnostic Outcomes (Strategies or actions for care) (Include source and page (Client’s response
(Realistic, timed, numbers) to nursing actions
statement) measurable) & progress toward
achieving goals
& outcomes)

1
Cox’s; pg. 149
Subjective:
Risk for infection R/T Baby will remain free Monitor vital signs every 4 hours Provides baseline and allows Baby L remained
from infection for for quick identifications of any free from infection
maturational factors and
duration of hospital deviations that could indicate
immature immune system stay. infection2
Institute aseptic precautions,
especially handwashing, around Protects baby from pathogens
infant.
Objective:

patient is 3 day old infant

Teach MOC about infectious


process, including routes,
pathogens, environment and host Provides basic knowledge for MOC was able to
MOC will verbalize factors. Include specific aspects of protecting newborn verbalize the
measures to decrease prevention: importance of
infection in her • Wash hands often, proper
newborn by end of especially before handling handwashing
shift infant or after changing
her diaper
• Do not allow sick friends
or family to interact with
infant

2
Cox’s pg. 54