Parent Newborn Nursing Case Study

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

2. 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

3. Medical History • History of depression • Cyst on ovary at age 14 • Arm surgery as child • Victim of domestic violence by parents • G1P0 • EDD 1/31/09 • Weeks gestation 40.5

4. Prenatal Lab Data

5. Labs Continued

6. Labor and Delivery Data • Vaginal delivery on 2/4/09 • Pain management via epidural • AROM 0848. Moderate amount of light meconium colored amniotic fluid. • Induction with Pitocin • Stage 1 – 29 hours 45 minutes • Stage 2 – 53 minutes • Stage 3 – 6 minutes • Total time 30 hours, 44 minutes

7. Mother’s Postpartum Assessment • Lung sounds clear • Bowel sounds present at all 4 quadrants • Breasts soft and nontender • Abdomen firm, FH -1 below • Lochia – moderate rubra • Pedal pulses +2 • Negative Homan’s sign in both extremities • Episiotomy midline and well approximated • BP, P &R WNL

8. Medications During Pregnancy • Folic 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.

9. Medications During Labor • Pitocin– 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.

10. Postpartum Lab Data

11. Nutritional Assessment • Prepregnant 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.

12. Newborn Data • Female • Gestational age 40.5 weeks • Apgar score • 1 minute=9 • 5 minutes=9 • Birth weight 6 pounds 11 ounces • 19” in length • Bottle feeding • Mother did not attend prenatal classes

13. Newborn Assessment • Temperature 97.8 • Pulse 124 • Respirations 32 • Skin pink • Lung sounds clear • Fontanels midline • Sucking, grasp, Babinski, rooting reflexes present

14. Newborn Medications • Vitamin 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

15. Postpartum Medications • Motrin-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 8.2 • TDAP – IM tetanus, diphtheria, acellular pertussisvaccine

16. Care Plan for Mother

17. Pain R/T episiotomy AEB 6 on pain scale • I - 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.

18. 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

19. Risk for ineffective coping R/T history of depression • I – 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.

20. 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.

21. Nursing Diagnoses for Newborn • Risk 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.