College of the Sequoias
Division of Nursing and Allied Health
NURS 153 – Care Plan/Verbal Report Guide
Student name: Shirlene Galutira Date(s) of Care: June 05, 2008 and June 06, 2008
Client Initials: DEL Room #: NICU Allergies: NKA
Age: 3 days old Ht: 20 inches Wt (lbs & kgs): 6 lbs 3 0z (2820 grams) Gender: Female
Admitting/Primary Diagnosis: Term infant w/ feeding intolerance, lethargy w/o evidence of obstruction; suspect sepsis
History of Present Illness including Signs & Symptoms: Baby girl is a 40 wk. gestation, born vaginally on 6/03/08. Mother is 19 yrs old, w/ no prenatal complications. There was loose nuchal cord & the infant was in good condition @ delivery. She was breastfed once & did well, but then remained gaggy & vomited & spit up multiple times in the ensuing 12 hours, despite gastric lavage. She was transferred to NICU (Neonatal Intensive Care Unit) for further evaluation & care.
Special Considerations for this child (developmental/play/cultural) that will affect your care:
Since the patient was transferred to NICU, it is important that the child is given appropriate attention because the child’s growth and development may be at risk. The child also has feeding intolerance which means that there could be imbalance nutrition which is very important factor in the growth and development in infants. So it is important that the nutritional needs of the patient is assessed and managed appropriately. I also need to consider the child’s mother, it is important that her mother is included in the care because the mother should show care also towards the child in order to develop the maternal and child bond. I should also consider the mothers emotion towards her child and the condition of her child because this may affect her attitude towards caring for the child. It may also affect the maternal bond which is important to the child at her condition. At this developmental stage for the child, it is important that I, as her nurse, should be calm and unhurried in providing the necessary intervention in order to make the infant feel safe and to develop trust in me and make the child feel comfortable.
Past Medical History: N/A
Recent Procedure(s) and/or Surgical Procedure(s)/Date(s): June 04, 2008 – Peripheral IV to right forearm. No other procedures noted.
24-hour Fluid Maintenance Requirement (mL/24 hrs): 1) TPN = 15 ml/hr
2) Lipid = 1 ml/hr
Intravenous Fluid Therapy:
Solution & Rate (why is the client receiving this type of solution?)
1) Dextrose 10% w/ TPN to run at 15 ml/hr via PIV
2) Lipid 20% to run at 1 ml/hr x 24 hours via PIV
Is the amount appropriate for the client? Yes
IV site (location & describe site): R forearm
System Assessment
Date: June 05, 2008 VS/O2 sat/Pain Scale:T=97.9 P=148 RR=55 BP= 78/44 O2=98%
Normal Parameters for age: T=97.9-99.4 P=85-205 RR=30-60
BP=90/70 O2=90%-100%
Date: June 06, 2008 VS/O2 sat/Pain ScaleT=98.6 P=156 RR=40 BP=76/45 O2=100%
Normal Parameters for age: T=97.9-99.4 P=85-205 RR=30-60
BP=90/70 O2=90%-100%
(Include assessment findings that correlate with all identified Nursing Diagnoses)
General Appearance: small, listless term infant in no distress, w/ little response to needle or sticks
Neurological: listless, less active than normal, w/ decreased tone & responsiveness. Normal reflexes for gestational age; brief sucking, resulting in gagging & retching.
Cardiovascular: RRR, no murmur, warm, well perfused, normal pulses; cap refill <3 secs.
Respiratory: bilateral clear lung fields, good air entry, no grunting, flaring or retractions.
Gastrointestinal: Feeding intolerance w/o distention; has bowel sounds & has stooled. Abdominal x-ray with multiple loops of small bowel gas, no evidence of destruction.
Genitourinary: normal female, anus patent
Musculoskeletal: back straight intact. Full ROM all joints; hips stable, negative Ortolani & Barlow maneuvers.
Integumentary: dry, poor turgor, yellow/pink
Psychosocial: Mother to be updated on infant’s status. MOB stated that she is still not happy that her baby is in NICU, but she understands that she needs to be there.
Based on growth and developmental stage, how will you approach this child?
At this stage the child is developing her sense of trust towards others. So it is important that the infant develops trust in me. It is important that her needs are provided, the approaches and intervention that I would be giving should be done in a more careful and unhurried approach. It is important that the infant receive a planned period of pleasing sensory stimulation. Like any newborns, it is important that the child receives stimulations such as touch, sounds, sight in order to be aware of the environment and people around. It is important that the child should be stroked or touched, any interaction that would stimulate the child for a healthy development and make the infant feel that they are cared for in order for them to develop trust in their healthcare provider. The infant should also be treated the same as that of a normal infant with just a little consideration of her needs because of her condition. It is also important that the parents especially the mother is included in the care in order for the child to also establish trust towards her mother.
Describe the Path physiology of the Admitting/Primary Diagnosis with signs and symptoms manifested by your client (Use a minimum of 3 resources):
Term infant with feeding intolerance, Lethargy without evidence of obstruction, suspect sepsis:
Feeding intolerance of infant is affected by many factors such as inability to suck, malabsorption of nutrition or factors such as obstruction in the gastric area. Thus the baby is at risk of imbalanced nutrition and dehydration compromising the health of the infant to receive adequate nutrition. Feeding intolerance can also be because of infectious diseases and other health problems that hinder the infant to engage in feeding.
Neonatal sepsis is an infection occurring in the first 90 days of life in an infant. The highest rates of neonatal sepsis occurs in infants having low birth weights, infants with respiratory depression and those babies with risk of maternal perinatal factors. Other predisposing factors include obstetric complication like rupture of premature membranes, placenta previa, abruption placentae, toxemia, precipitous delivery or maternal infection. Late onset of neonatal sepsis is attributed to prolong use of intravascular catheters. Other factors that contributes to neonatal sepsis is the prolong exposure or used of antibiotics that results in resistant bacteria. Prolong stay of infants in the hospital risks them to sepsis because of the exposure to hospital acquired infection. Prolonged use of central IV catheters, hyper alimentation and other infectious diseases also contributes to neonatal sepsis. The sign and symptoms of sepsis includes less spontaneous activity, less vigorous sucking, lethargy and fever is common due to the infection. Other signs include respiratory depression, neurologic problems of the baby, jaundice.
Lethargy is usually caused by many factors such as neurologic disorders, hyperthyroidism, hypothyroidism it can also be caused by kidney failure. Inadequate nutrition causes lethargy because there is not enough energy in the body to be utilized thus causing lethargy and weakness. Although lethargy can be considered as a simple matter to some, lethargy or listlessness can mean something fatal if not assessed and managed properly.
Resources/References (3 or more):
Pillitteri, A., (2006). Maternal and Child nursing: Care of the Childbearing and Childrearing Family 5th edition,. Philadelphia: Lippincott Williams and Wilkins
The Mercks manual online library. (2005). Neonatal sepsis. Retrieved June 14, 2008 from http://www.merck.com/mmpe/sec19/ch279/ch279m.html
Kietzman, S. (2008). What are some causes of Lethargy. Retrieved June 14, 2008 from http://www.wisegeek.com/what-are-some-causes-of-lethargy.htm
Explain the potential complications/nursing concerns with this diagnosis, especially those for which your client is at risk for:
The client is at risk for imbalanced nutrition because the baby has feeding intolerance. Although the infant is receiving TPN and has been fed with infant formula the baby was kept NPO because the baby developed gagging thus risks the baby to have an imbalanced nutrition. The baby also has sucking problems resulting into gagging and vomiting thus making breast feeding and formula feeding hard for the baby. Since the baby is not receiving enough nutrition the baby is lethargic, weak and unresponsive to some stimuli.
The baby is receiving TPN thus there is a risk for infection; infection is a major danger in TPN because the solution is perfect medium for growth of bacteria. It is important that the dressing over the insertion site and intravenous tubing should be changed every one or two days to avoid infection; the tubing should not be used for drawing blood or for adding medications because this may introduce infection. The site should also be inspected for indications of local infection such as redness, tenderness or discharges.
Another complication is dehydration can also be related to the infants feeding intolerance. Since the infant is receiving TPN to provide the nutritional needs of the child she may be at risked of dehydration. TPN solutions contain approximately twice the amount of glucose normally administered in an intravenous solution to ensure that the amino acids in the solutions will be used for protein synthesis and not for energy. Dehydration may occur as the body tries to reduce the amount of glucose recognized by the kidney as an excess by excreting it.
Because the infant is in NICU, there is a compromised family coping. Since the infant has to stay in the NICU, the parents are limited in their interaction with the child. The parent’s knowledge and understanding with regards to the infants condition is also limited thus parent-infant boding is interfered. The parents may feel that their role as parents is impaired thus interfering with the family coping.
List any strategies being used to enhance Family-Centered Care:
Encouraging the parents to visit the child regularly to help form a strong parent- child attachment.
If the parents are not allowed to visit, encourage them to phone the hospital as frequently as they can to inquire about their child.
To encourage a good parent-child relationship, tell the parents about the positive things that the infant can do and the development and improvement in the infant in her care.
Help the parents interact more fully with their infants in order to build a sense of trust in the infant. You can include mother in feeding the infant and the father can gain trust by a simple touch or stroke that would stimulate the child. Touch therapy is known to contribute to an infant’s growth and development especially children who have problems, a simple touch can help the infant recognize that she is cared for and loved by her parents.
Urge parents to continue to give as much care and time to their baby because parent- infant attachment is critical in the mental health of babies.
Top 5 Nursing Diagnoses: (In Order of Priority)
Note: AMBs must be measurable!
1.
Risk for imbalanced nutrition, less than body requirements
R/T
Feeding intolerance
AMB
Small, listless child, dry and poor skin turgor, brief sucking, gagging and vomiting
2.
Risk for dehydration
R/T
Feeding intolerance
AMB
Dry and poor skin turgor, infant is less responsive to stimuli, poor sucking gagging and vomiting
3.
Risk for infection
R/T
contamination of the catheter site or infusion line
AMB
Dry and poor skin turgor, impaired skin integrity due to prolong bed rest
4.
Risk for impaired parenting
R/T
interference with parent-infant attachment
AMB
Prolong hospitalization of infant at birth, MOB verbalized that she is not happy to see her child’s condition
5.
Knowledge deficit
R/T
Treatment regimen
AMB
MOB verbalization that she doesn’t understand what is happening to her child
Nursing Diagnosis #1
Risk for imbalanced nutrition, less than body requirements r/t feeding intolerance
Goal:
The patient will improve feeding and maintain optimal nutrition
Assessment Interventions:
-The patient is assessed for:
weight loss
milk intake/breast feeding
sucking reflex
skin turgor and appearance
-The baby’s bowel sound was checked in order to see if there is peristalsis or any distention that may cause malabsorption of nutrients.
-intake and output is measured and recorded
Evaluation (Day 1):
The baby has brief sucking, gagging and vomiting noted after feeding, the baby is also lethargic and has limited response to stimuli. Patient was placed in NPO because of gagging and retching, limited weight loss, positive bowel sounds, no noted distention
Evaluation (Day 2):
The babies skin is still dry and has poor skin turgor, still listless, still NPO because the patient again developed gagging, no noted weight loss. Still noted with brief sucking
Therapeutic & Med Interventions:
Initiated gastric lavage
TPN, lipid was started
formula feeding was also initiated
Evaluation (Day 1):
The patient is still sucking briefly, gastric lavage was provided but developed gagging and so was NPO. TPN was initiated in order to provide nutrition to the child. The baby was also provided with formula feeding still vomited and spit up
Evaluation (Day 2):
the patient is still not eating well, still developing gagging and still vomits upon formula feeding, no weight loss noted
Teaching/Anticipatory Guidance:
Taught the mother the importance of proper nutrition on her baby
Encouraged the mother to breast fed the baby when the baby is able to suck
Demonstrate and taught the mother proper way of feeding the baby
Evaluation/ Evidence of Successful Learning:
MOB demonstrated and verbalized the importance of proper feeding and nutrition of her baby especially at her condition.
Special Learning Needs:
Goal Evaluation:
Goals partially met, patient was able to maintain nutrition but still no improvement on feeding
Nursing Diagnosis #2
Risk for dehydration r/t feeding intolerance
Goal:
the patient will maintain to be hydrated, will have a good skin turgor and will improve sucking reflex
Assessment Interventions:
Assessed the patient’s skin turgor and appearance
Assessed the patient weight for weight
Assessed child’s response to stimuli
Evaluation (Day 1):
Dry and poor skin turgor, there is limited weight loss, the child still appears listless and little respond to stimuli
Evaluation (Day 2):
No weight loss noted, child is lethargic, still less responsive to stimuli
Therapeutic & Med Interventions:
Measured intake and output
Initiated formula feeding as tolerated by the baby
TPN continued as ordered
Evaluation (Day 1):
Formula feeding initiated, still with vomiting and gagging, intake is adequate, has stooled, still with brief sucking
Evaluation (Day 2):
Still no improvement
Teaching/Anticipatory Guidance:
Teach the mother the importance of breast feeding the child if tolerable
Taught the mother the importance of adequate intake of liquid for the baby in order to maintain hydration
Allowed the mother to stimulate the baby such as touch, talking to the baby
Evaluation/ Evidence of Successful Learning:
The verbalized the importance of breast feeding and has agreed to breast fed baby once tolerated. The mother also verbalized understanding with regards to touching and stimulating her baby in order to develop parent-child bond.
Special Learning Needs:
none
Goal Evaluation:
Goal partially met, patient was maintained hydrated by still noted with feeding intolerance, poor sucking
Nursing Diagnosis #3
Risk for infection r/t contamination of catheter site or infusion tube
Goal:
To prevent infection of the catheter site and infusion tube and maintains a good skin integrity
Assessment Interventions:
Assessed the patient’s skin integrity for swelling, redness
Assessed the catheter site
Assessed the infusion tube and dressing
Evaluation (Day 1):
Noted no swelling, redness and skin is intact, catheter site is intact and infusion site and dressing free from discharge
Evaluation (Day 2):
No noted discharge on the dressing, swelling or redness in the infusion site, skin integrity intact
Therapeutic & Med Interventions:
Skin was kept dry and the linen and clothing were also kept dry
The patient’s skin was inspected every 2 hours, the patient was turned every two hours as well
Dressing were changed and infusion tube was replaced every 2 days
Evaluation (Day 1):
Skin integrity is intact and skin is dry and free from any infection, dressing were done and no noted discharge or swelling and redness.
Evaluation (Day 2):
Skin integrity is maintained and intact free from any risk of infection
Teaching/Anticipatory Guidance:
Demonstrate to the mother of the baby the proper way to clean the babies skin
Inform the mother the importance of nutrition as this helps maintaining a good skin integrity
Inform the mother to report any complications
Evaluation/ Evidence of Successful Learning:
The mother verbalized and demonstrated the importance of maintain a good skin integrity and proper nutrition in order to promote good skin integrity and energy. Catheter site is intact no noted complications.
Special Learning Needs:
none
Goal Evaluation:
Goals met, as the patient is free from risk of infection and maintained a good
College of the Sequoias
Division of Nursing and Allied Health
NURS 153 – Pediatric Laboratory Analysis Sheets
CBC
Normal Reference Range for Age
Clients’ Value
(Highlight Abnormals)
Date: June 05, 2008
Client’s Value
(Highlight Abnormals)
Date: June 04, 2008
WBC
5.0-26.0
12.10
16.20
RBC
4.70-6.20
5.13
4.85
HGB
17.0-22.0
19.50
18.70
HCT
58.0-74.0
55.10 low
53.40
MCV
107-119
108.0
110.10
MCH
33.0-41.0
38.10
38.60
MCHC
28.0-32.0
35.4 high
35.0 high
PLT
300-750
261.0 low
279.0 low
…Neutrophil %
42.0-72.0
56.10
70.30
…Lymphocyte %
17.0-45.0
29.0
20.50
…Mononuclear %
3.0-10.0
11.20 high
7.0
…Eosinophil %
1.0-10.0
1.91
1.30
…Basophil %
0.0-5.0
0.947
0.90
Neut Abs Cnt
1.6-8.30
6.780
11.40 high
Lymph Abs Cnt
1.0-4.50
3.62
3.30
Mono Abs Cnt
0.10-0.90
1.350 high
1.10 high
Eos Abs Cnt
0.0-0.55
0.23
0.20
Baso Abs Cnt
0.0-0.20
0.115
0.10
Other:
Other:
Discuss Analysis/Trends (, ¯, WNL):
Low HCT= indicates that the patient may suffer from anemia, dehydration and bleeding.
High MCHC= indicates that there is too many hemoglobin in the blood, indicating that there is a high level of iron in the blood. Iron excess can be damaging as damaging as deficiency in iron.
Low platelets= indicates that there could be bleeding or an excessive destruction of platelets due to parasites or immune diseases.
High mononuclear= due to infection
High Mono Abs Cnt= due to infection
College of the Sequoias
Division of Nursing and Allied Health
NURS 153 – Pediatric Laboratory Analysis Sheets
Chemistry Panel
Normal Reference Range for Age
Clients’ Value
(Highlight Abnormals)
Date: June 05, 2008
Clients’ Value
(Highlight Abnormals)
Date: June 04, 2008
Sodium
132-142
132
138
Potassium
4.0-6.2
4.9
4.0 low
Chloride
96-106
102
103
Carbon Dioxide
18-27
19
22
Anion Gap
4-16
16
16
Glucose
51-90
38 low
67
BUN
5-15
9
11
Creatinine
0.1-0.6
0.61 high
1.08 high
BUN/Creat Ratio
6-27
14.8
10.2
Protein
4.4-7.6
4.6
5.0
Albumin
2.4-4.8
2.7
3.0
Calcium
7.0-12.0
8.0
8.6
Phosphorus
5.8-9.0
5.7 low
4.8 low
Magnesium
1.5-2.3
1.6
1.6
Triglycerides
10-140
31
62
Alk P-Tase
85-368
137
162
SGOT (AST)
18-74
67
113 high
SGPT (ALT)
18-74
16 low
17 low
Total Bili
4.0-6.0
9.5 high
6.6 high
Direct Bili
0.1-0.5
0.4
0.3
Indirect Bili
0.1-0.8
9.1 high
6.3 high
CRP
<7.48
1.12
1.15
Discuss Analysis/Trends (, ¯, WNL):
*Low potassium= due to vomiting may cause muscle weakness, fatigue and decreased bowel motility.
*Low glucose= indicates hypoglycemia due to feeding intolerance
*High Creatinine= indicates that the kidney is not functioning well thus accumulation of creatinine. This also indicates that the client is at risk for dehydration, the patient may manifest muscle weakness too
*Low phosphorus= can cause damage to the bone, muscles and nerves
*High SGOT=due to Liver immaturity
*Low SGPT=due to Liver immaturity
*High Bilirubin= hyperbilirubin due to liver and kidney immaturity
College of the Sequoias
Division of Nursing and Allied Health
NURS 153 – Pediatric Diagnostic Procedures
Procedure
Date(s)
Discuss Analysis/Trends/Reason for Procedure
CXR
X-Ray
06/04/08
Infant Chest/Abdomen
Impression: No consolidating infiltrates or effusions w/ overall non-specific appearing bowel gas pattern.
X-Ray
06/05/08
Infant Chest/Abdomen
Impression: Vague atelectasis changes @ the infrahilar right lung base. Otherwise, unremarkable.
MRI
CT Scan
Other: