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

Parent Newborn Nursing Case Study

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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 - PowerPoint PPT Presentation

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Page 1: Parent Newborn Nursing Case Study

Parent Newborn Nursing Case Study

Tammy BailesMellanie Hopkins

Tiffany KentChristen Miller

Page 2: Parent Newborn Nursing Case Study

Mother’s Profile

L.S.Age 24Reason for admission – deliveryFormer ½ pack per day smokerNo alcohol or drug useNo prenatal classes

Page 3: Parent Newborn Nursing Case Study

Medical HistoryHistory of depressionCyst on ovary at age 14Arm surgery as childVictim of domestic violence by parentsG1P0EDD 1/31/09Weeks gestation 40.5

Page 4: Parent Newborn Nursing Case Study

Prenatal Lab DataPrenatal Test Norms Patient

ResultsAnalysis

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 Non reactive No sign of syphyllis.

Rubella Immune Immune Will not need vaccination.

Urine C&S N/A N/ASickle Cell N/A N/A

Page 5: Parent Newborn Nursing Case Study

Labs ContinuedPrenatal Tests Norms Patient

ResultsAnalysis

Chlamydia Gonorrhea

Negative Negative No infection.

PAP test Normal WNL No sign of cancerous cells.

Triple Screen N/A N/A1 Hour Glucose Screen

70-139 mg/dl Patient could not tolerate

Not determined.

Page 6: Parent Newborn Nursing Case Study

Labor and Delivery DataVaginal delivery on 2/4/09Pain management via epiduralAROM 0848. Moderate amount of light

meconium colored amniotic fluid.Induction with PitocinStage 1 – 29 hours 45 minutesStage 2 – 53 minutesStage 3 – 6 minutesTotal time 30 hours, 44 minutes

Page 7: Parent Newborn Nursing Case Study

Mother’s Postpartum AssessmentLung sounds clearBowel sounds present at all 4 quadrantsBreasts soft and nontenderAbdomen firm, FH -1 belowLochia – moderate rubraPedal pulses +2Negative Homan’s sign in both extremitiesEpisiotomy midline and well approximatedBP, P &R WNL

Page 8: Parent Newborn Nursing Case Study

Medications During PregnancyFolic 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.

Page 9: Parent Newborn Nursing Case Study

Medications During LaborPitocin – 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.

Page 10: Parent Newborn Nursing Case Study

Postpartum Lab DataTests Norms Patient

ResultsAnalysis

WBC 5,000-10,000 mm325,000-30,000 mm3 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 8.2L AnemiaHct 38-47 24.8L Loss of blood,

anemia

Page 11: Parent Newborn Nursing Case Study

Nutritional AssessmentPrepregnant 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.

Page 12: Parent Newborn Nursing Case Study

Newborn DataFemaleGestational age 40.5 weeksApgar score

1 minute=95 minutes=9

Birth weight 6 pounds 11 ounces19” in lengthBottle feedingMother did not attend prenatal classes

Page 13: Parent Newborn Nursing Case Study

Newborn AssessmentTemperature 97.8Pulse 124Respirations 32Skin pinkLung sounds clearFontanels midlineSucking, grasp, Babinski, rooting reflexes

present

Page 14: Parent Newborn Nursing Case Study

Newborn MedicationsVitamin 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

Page 15: Parent Newborn Nursing Case Study

Postpartum MedicationsMotrin-600 mg PO q8h– for mild to moderate

pain. Tylenol 3 – 1-2 tablets PO q4h PRN for

moderate pain.Ferrous sulfate – Iron supplement for anemia.

L.S. postpartum hemoglobin at 8.2TDAP – IM tetanus, diphtheria, acellular

pertussis vaccine

Page 16: Parent Newborn Nursing Case Study

Care Plan for Mother

Page 17: Parent Newborn Nursing Case Study

Pain R/T episiotomy AEB 6 on pain scaleI - 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 q6 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 the therapeutic effects of pain relief medications.

Page 18: Parent Newborn Nursing Case Study

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 q4h.R: Provides a baseline that allows quick recognition of deviations in

subsequent measurements. I – Monitor episiotomy at least q4h 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 q4h for

48h.R: Provides database necessary to screen for infection

Page 19: Parent Newborn Nursing Case Study

Risk for ineffective coping R/T history of depressionI – 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.

Page 20: Parent Newborn Nursing Case Study

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.

Page 21: Parent Newborn Nursing Case Study

Nursing Diagnoses for NewbornRisk 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.