Question

Client Profile

Baby Martin was born via a normal spontaneous vaginal delivery (NSVD) at 36 weeks gestation. The mother arrived at the emergency room dilated to 9 centimeters and 100 % effaced. The mother also reports ruptured membranes for the past 22 hours. The fetal heart rate upon admittance to the emergency room is 170 bpm. The mother delivered in the emergency room 30 minutes after being examined. This is her seventh pregnancy, and she did not have prenatal care.

Case Study

Martin was admitted to the observation nursery from the emergency room where he was born. He weighed 5 pounds and was 19 inches long. His APGAR scores were 6 at one minute, and 8 at five minutes. Points were initially taken off for tone, reflexes, and color. His initial glucose was 35 and vital signs were heart rate 150, respirations 76, and temperature 97.2. The nurse noted some nasal flaring, grunting, and coarse breath sounds. He was given 1 ounce of D5W orally; oxygen therapy, and his skin and pharynx were cultured. The orders also included that he be placed on a warmer with skin probe for temperature monitoring.

At two hours the baby's glucose was 40, the nasal flaring continued, respiratory rate was 100 with continued coarse breath sounds. He exhibited acrocyanosis, and his temperature was 96.8. The baby was treated for transient tachypnea of the newborn with oxygen therapy and a warm environment.

At four hours the nurse noted that the baby was lethargic and difficult to arouse. He appeared pale with circumoral cyanosis, nasal flaring, and grunting with sternal retractions. The nurse notified the doctor, an IV was started, and the baby was transferred to the neonatal intensive care unit at a hospital in the next town.

At six hours the mother called the NICU to check on his progress and was told that he had subsequently developed jaundice and was on a ventilator.

Questions (please cite if you use a source)

1.Write two complete nursing diagnoses stating the diagnosis with r/t and AEB statement, goal/plan which must be measurable, 3-4 interventions, and evaluation criteria. One diagnosis for the mother and one for the infant. (should be NANDA approved nursing diagnoses)

2.What do you see your role as a nurse in this entire situation from being called to the ER through the transfer of the infant, and the continued care of the mother until discharge? ( please be detail)

Answer 1

QUESTION-1

NURSING DIAGNOSIS

FOR INFANT;

-Deficient fluid volume related to inadequate fluid intake or phototherapy or diarrhoea as evidenced by dehydration and impaired skin turgor

GOAL'

-To maintain adequate body fluids

-To reduce the complications

   -To maintain hydration and pulmonary status

-To prevent the sepsis

INTERVENTIONS

-Record number and quality of stools

-Monitor skin turgor

-Monitor intake and output charts

-Maintain breastfeeding

-Chech vital signs every two hours

EVALUATION CRITERIAS  ARE;

The evaluation criterias types are listed below;

1-Relevance

Measure the qualities of an interventions

   2-Efficiency

-The number of resources used and immediate observable results of positive interventions

3-Effectivess

-Assess the outcomes or result of an interventions and wheather acheived the specified goals or not

4- Impact

Assess the impact of the interventions like positive or negative result

5- Sustainability

-The extent to which interventions has been successfully completed or to be continued

Evaluation criterias as follows;

- APGAR SCORE;

A-APPEARANCE

P-PULSE RATE

G-GRIMACE(reflux or irritability or responses)

A-APPEARANCE

R-RESPIRATION

  

-Fluid refractory shock

-Hypoxia

-Higher respiratory rates

-Presence of tissue effusion

-Increasing breathing workloade

-Tachypnoea

-Dyspnoea

-Nasal flaring

-Apnoea

-Pulse oximetry measurements

OTHER NURSING DIAGNOSIS FOR INFANTS ARE AS FOLLOWS;

-HYPERTHERMIA RELATED TO EFFECTS OF PHOTOTHERAPY

-INEFFECTIVE TISSUE PERFUSION RELATED TO IMPAIRED TRANSPORT OF OXYGEN ACROSS ALVEOLI

-INTERRUPTED BRESTFEEDING RELATED TO NEONTES PRESENT ILLNESS AS EVIDENCED BY SEPERATION OF MOTHER TO INFANT

NURSING DIAGNOSIS FOR MOTHER

-Risk for fluid volume deficit related to blood loss as evidenced by wekaness and dehydration

Goal

-To maintain hydration status

-To restore mother health

-To monitor the lvel of blodd loss and record the amount of blodd loss

-To chech the vital signs

Interventions

-Assess the current health status of the mother

-Administer intravenous fluids

-Maintain input and output charts

-Assess for;

-hydration status

-pulmonary status

  -respratory rates

  -cardiac status

-temperature regulations

-neurological status

-Provide complete bed rest and personal hygeine

EVALUATION CRITERIA

-Breast examination

-Assess the fundal height

-Assess for bladder functions

-Assess for bowel functions

-Lochial discharge assessment

-Episiotomy area assessment

-Homans sign(vericos vein in the legs)

-Emotions

QUESTION -2

CARE OF THE INFANTS

While transfering an infants the followig criterias have to follow;

-proper weight

-in stable condition

-with stable enterostomy or gastrostomy

-on oral medications

-on phototherapy

-on intravenous therapy for medications

NURSES ROLE;

-Consent from the parents

   -Assess the level of care needed

   -Copy of neonates charts

   -Copy of progress charts

  -Lists of neonates existing or unresolved problems

-Stable nutritional status

-Respiratory evaluations

-Do physical examination

-Assessment for well-being

CARE OF MOTHER

Objectives are;

-to restore the health status of the mother

-to prevent the complications of puerperium

-provide basic postpartum care

  -motivate, educate and provide family planning services

-to check the adequecy of breast feeding

NURSING INTERVENTIONS ARE;

-Assess for the following;

-an excessive postnatal bleeding

-puerperal pyrexia

-puerperal sepsis

-involution of the uterus

-breast complications like mastitis,breast engorgements,cracked nipples etc

-exclusive breast feeding

-Maintain nutritional status

-help for post natal exercises

-administration of intravenous fluids

-maintain intake and output charts

-educate about post natal visits and follow up care

-importance of immunization

-provide easily digestible diet and assess the bladder and bowel functions

-assess the warning signs of sepsis like hyperthermia

-provide comfortable positions and rest

-assess for urination,urinary incontinence ,healing of perineal wound

-assess for headache ,fatigue,backpain,perineal pain,uterine tenderness and lochia

NURSING DIAGNOSIS

-ACTIVITY INTOLERANCE

-SLEEP PATTERN DISTURBANCES

-BODY IMAGE DISTURBANCES

-HIGH RISK FOR INFECTION

-HIGH RISK FOR KNOWLEDGE

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