Transcript Parent Newborn Nursing NURS 30010 Summer 2001 Postpartum

Kerry, Kris, & Megan
 G2P2L2
 Baby girl
 7lb 6oz
 born may,25, 2011
 38wks 6 days gestation
Prenatal
Data
Lab Data
Diagnostic Tests
Prenatal Medications
 WBC 10.55
 RBC 2.89
 Platelate 180
 Hgb 8.2
 Hct 24.2
 Urinalysis – No Growth
 Blood Glucose- 116
 Sickle cell – no trait
 Syphilis-negative
 Hepatitis- positive for antibodies
 Vital signs- 36.9 88 20
 Blood type – A-
112/66
 Ultrasound
 16 weeks, showed size, structure, growth WNL
 Baby girl
 Prenatal vitamins- 1 tab daily to prevent risk of neural
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tube defects. Can cause nausea
Folic acid
Vitamin D,C, B12, E
Iron
Calcuim
Thiamine
Niacin
Riboflavin
zinc
 RhoGam
 Why it is given
 When it is given
Labor and
Delivery Data
 Cesarean birth
 IV running
 Monitored vitals for the mom and fetus
Post Partum
Data
Head to Toe
Assessment
Laboratory Data
Medications and
Procedures
Nursing diagnosis
Time
Temp in C
Pulse
Resp.
BP
0800
36.8
72
16
122/66
1200
36.9
88
20
116/70
1500
36.9
80
16
120/76
Time
Pain Level
Intervention
0700
6-7
Motrin
0800
3
1200
5
1300
2-3
Motrin
 Breasts
 Uterus
 Bladder
 Bowels
 Lochia
 Episiotomy ( in her case, incision site)
 Breakfast: Cereal with milk, juice, bacon, a muffin, and
a doughnut
 Lunch: 480 cc Dr. Pepper and ate 50% of hospital
provided lunch
 Snack: chips, Snickers and several mini cupcakes
Blood Components
Pt. Values
Normal Value
WBC
8.16
5-10
RBC
3.39
4.2-5.4
HGB
8.2 g/dl
12-16 g/dl
HCT
32.2%
38-47%
Platelets
174
150-450
Medications
Dosage
RhoGam
20 mcg IM
Ferrous Sulfate
325 mg
Multivitamin
1 tablet
Lanolin
Topical
Motrin
600 mg
 Risk for more than body requirements – The state in
which an individual experiences or is at risk for
experiencing weight gain R/T an intake in excess of
metabolic requirements
 Short Term Goal
 Long Term Goal
 Interventions
 Actions
 Risk for Disturbed body image – The state in which an
individual experiences or is at risk to experience a
disruption in the way they perceive their body
 Short Term Goal
 Long Term Goal
 Interventions
 Actions
 Risk for parental role conflict – The state in which a
parent experiences or perceives a change in role in
response to external factors
 Short Term Goal
 Long Term Goal
 Interventions
 Actions
New Born Data
Assessment
Laboratory Data
Medications
Nursing Diagnosis
 Vitals: pulse rate 126, respirations 36, and auxiliary
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temperature 36.5
Weight: 7lb. 6oz.
Length: 20.3 in.
Blood sugar: 97mg/dL
Lab tests: negative for PKU and passed hearing test
Assessment: lung sounds, skin warm, dry and intact,
bowel sounds present, all neurological reflexes
present, Cry strong and lusty, umbilical cord drying;
vagina and anus visible and patent
 Cord blood Gas Analysis
Blood test
Norms
Patient results
Analysis
pH
7.23 – 7.33
7.312
With in Normal Limits
(WNL)
Pco2
40.6 – 57.4
50.2
WNL
Po2
11.8 – 24.2
12.4
WNL
HCO3 -
19.5 – 24.5
28.4
Metabolic Alkalosis
 Erythromycin Ophthalmic
 Action: Suppresses protein synthesis at the level of the 50S bacterial
ribosome
 Administration: Soon after delivery, by placing about .5 to 1 centimeter
of 0.5% medication on each eye
 Vitamin K (IM)
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Action: required for hepatic synthesis of blood coagulation
Administration: given within one hour of birth in Vastus lateralis
 Hepatitis B vaccine (IM)
 Action: provides antibodies to the hepatitis B surface antigen resulting
in passive immunity to hepatitis B
 Administration: Given before discharge in the Vastus Lateralis. A
second dose is given at one month of age and a third final dose is given
at 6 months of age.
Risk for Impaired gas exchange related to amino fluid
retained in infants lungs secondary to caesarian section
delivery.
 Short term Goal
 Long term Goal
 Interventions
 Actions
 What we did right
 What we could have spent more time on
 What we did not consider
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