case study for parent and newborn...

Nursing Process Paper 1

Running head: NURSING PROCESS PAPER

Case Study for Parent and Newborn (30010)

Christopher Roth, Bridgett Gillespie, Kristen Weaver

Kent State University


Introduction

Client A.H. is a 24-year-old female that was admitted because she was full term and due. Client

was chosen for this Nursing Process paper because of complications explained below that

resulted in mom requiring a cesarean section “Delivery of the fetus by means of incision into the

uterus. Operative approaches and techniques vary. A horizontal incision through the lower

uterine segment is most common. The most common reason for emergency cesarean delivery is

fetal distress” (Venes et al. 2005, p. 382). This paper will discuss the background of the patient,

antenatal history, any relevant pathophysiology, assessments, lab results, medications, and

nursing interventions. The newborn’s labs, medications, and assessment findings along with any

pertinent information will also be explained.

Demographics

Client has no known allergies and does not smoke. She rarely drinks alcohol and does not use

any drugs recreationally. Significant family history of diabetes mellitus, heart disease and

hypertension is present. Past surgical history of client: inguinal hernia repair at seven years of

age, as well as a shoulder surgery at age fifteen, and wisdom teeth removed. Client’s education

includes attending Altman hospital for RN program. She still has to take the NCLEX boards.

Client works part-time for Alliance Community Care Center. A.H. described her religion as

being Presbyterian. Her husband was present for support and is involved with the care that both

the mom and newborn receive. Also, many family members have come to visit her and the

newborn baby.


Obstetric/Antenatal history/Relevant pathophysiology

Client has no past history of sexually transmitted infection, or gynecological disorders or

surgeries. No diet restrictions were placed on the mom. Her husband has accompanied her to

three prenatal classes which included a labor and delivery class, breast-feeding, and a baby care

class. Mom has had previous experience, as a nursing student working with newborns and also

teaching patients proper care for newborns, however she still wanted to take classes to ensure

that both mom and dad are comfortable with the new experience. Client’s last menstrual period

was March 12, 2010 and according to Nagele’s Rule client’s EDB would be on January 17,

2011. Nagele’s Rule

is used to determine the EDB by taking the first day of the last menstrual period,

subtracting 3 months and adding 7 days; this date is most accurate when the woman

remembers her last menstrual period, has menses every 28 days, and was not taking oral

contraceptives (Hogan et al. 2007, p. 107).

A.H. is primigravida, “a women during her first pregnancy” (Venes et al. 2005, p. 1773). Before

this pregnancy client was (GTPAL)-zero. This means that she has never been pregnant, zero term

babies, zero preterm babies, zero abortions, and zero living children. “Gravita-any pregnancy,

regardless of duration, including present pregnancy. Term-The normal duration of pregnancy (38

to 42 weeks’ gestation). Para-Birth after 20 weeks’ gestation, regardless of whether the infant is

born alive or dead. Abortion-Birth that occurs before 20 weeks’ gestation” (Olds et al. 2004, p.

323). Number of weeks gestation for mom 41/1.

Assessment

Mom- Client admitted on 1/24/2011 at 0721 to delivery room. There were no advanced

directives or code status. Problems with this pregnancy include non-reassuring fetal heart tones


and the umbilical cord wrapped around baby’s leg three times. Umbilical cord is “the structure

connecting the placenta to the umbilicus of the fetus and through which nutrients from the

woman are exchanged for wastes from the fetus” (Olds et al. 2004, p.1148). Also, abnormal cord

insertions are strongly associated with abnormal FHR patterns (Hasegawa, 2009, p.37). Non-

reassuring fetal heart tones include late decelerations which are “symmetrical decrease in fetal

heart rate beginning at or after the peak of the contraction and returning to baseline only after the

contraction has ended, indicating possible utero-placental insufficiency and potential that the

fetus is not receiving adequate oxygenation” (Olds et al. 2004, p. 1141). C-section was

unscheduled and ordered after non-reassuring heart tones and cord complication. C-section

incision was a low transverse uterine incision and well approximated with no REEDA. Reeda

stands for “R= redness, E= edema or swelling, E=ecchymosis or bruising, D=drainage, A=

approximation (how well the edges of an incision-the episiotomy-or a repaired laceration seem to

be holding together)” (Olds et al. 2004, p. 1010). Placental delivery was charted manual.

Placenta appearance was charted as intact. Vitals for mom the day of clinicals, 1/26/2011. 0800-

36.7, 76, 15, 118/58. Pain of 2. Client said she would take any PRN's to stay on top of pain. At

0900 a vitamin, Motrin-600mg and Percocet 325 mg given. 1000-Pain reassessed 2. Vitals for

1500- 36.7, 65, 15, 110/54, pain of a 4, 1500- Motrin and Percocet given. Reassessed at 1600.

Pain went down to a 2.. 1350-Tdap given. At 0800 assessment of mom there was nothing out of

range besides +1 edema in bilateral feet. Also, the uterus was mid-line -2 station, and the left

nipple was leaking colostrum with both breasts tender. 1500 complete assessment normal besides

+1 swelling in bilateral feet. Right nipple tender, nursing specialist called into room to help

client. Scant lochia Rubra. The newborn had an Apgar score of 9/9 “Apgar Scoring system is

used to evaluate the physical condition of the newborn at birth and the immediate need for


resuscitation. The newborn is rated one minute after birth and again at five minutes and receives

a total score ranging from 0 to 10” (Olds et al. 2004, p.652). Please refer to table after Reference

Section. Client received an Epidural for pain. An “epidural block-very small diameter catheter is

inserted into potential space between Dural layers of lumbar spine and local anesthetic agent is

injected to produce labor analgesia or anesthesia” (Hogan et al. 2007, p. 170). Hemoglobin was

9.7 so 325mg of Ferrous sulfate “Iron” was given at 1030. 1046 Benadryl given due to patient’s

complaint of feeling itchy. Patient was up as needed. Stages of labor included the rupture of

membranes on 1/24/11, and birth of newborn at 0136, placenta at 0137 on 1/25/11. The stages of

labor are divided into the first stage, second stage, third stage and fourth stage.

The first stage begins with the onset of regular contractions and ends with complete

dilatation 10cm. The second stage of labor begins when the cervix is completely dilated

(10cm) and ends with birth of the infant. The third stage of labor is defined as the period

of time from the birth of the infant until the completed delivery of the placenta. The

fourth stage of labor is the time from 1 to 4 hours after birth in which physiologic

readjustment of the mother’s body begins” (Olds et al. 2004, p. 570-574).

Pre-pregnancy weight of 132 pounds and current weight of 161 pounds. Total weight gained 29

pounds. Mom stated that her desired weight will be 125 pounds. She normally exercises about

three times a week and would like to continue workout schedule postpartum. Client cooks for

family and does not have any concerns about her nutritional habits, and does not have any

diseases related to nutrition. Client shops with husband and does not participate in WIC or food

stamp programs. Normally, client snacks about two to three times a day on small items such as

fruit or granola bars. Patient has a regular diet without racial or ethnic considerations for hospital

to consider. Client has not abused laxatives or stool softeners and has increased fluid intake


throughout pregnancy. Observed client bonding with newborn by cuddling baby and performing

basic parental tasks.

Newborn Assessment

Newborn boy’s initials C. H. Vitals for 0800 are 37.3, 123, 53, NIPS <3. Vitals for 1500 36.7,

135, 47 and < 3 for NIPs pain assessment. Newborn peed first large amount at 1500. Date of

birth on January 25, 2011 at 0136. C. H. weighed 8lbs and 6oz or 3647 grams. Last night, on

1/25/11, weight 7.14lbs. Blood sugar was 75. Hub’s tag number is 54 and newborn is already

circumcised. A&D ointment has been applied with every diaper change. Gestational score for

mom is 41 weeks and1 day. Ballard score for newborn is 41 which correlates to 40weeks and 3

days. The Ballard score is

A system for estimating newborn gestational age by rating physical and neuromuscular

characteristics of maturity. For infants born between 20 and 28 weeks gestation, Ballard

tools are more accurate than other systems of estimating gestational age. Five

neuromuscular markers are assessed: posture, square window (degree of wrist flexion),

arm recoil, popliteal angle (degree of knee flexion); scarf sign (ability to extend infant’s

arm across the chest past the midline); and heel-to-ear extension. Seven physical

characteristics are also evaluated: skin; lanugo; plantar creases; breast; eye and ear; and

genitals/ each factor is scored independently, and then an overall sum is used to

determine the gestational age. The tool is most accurate if performed within the first 12 to

20 hr of life, or as soon as the baby’s condition stabilizes (Venes et al. 2005, p. 219).

Newborns class is AGA, or average for gestational age. Maturity level is equal to a term

newborn. Measurements of head to heal is 48.3cm or 19.0in. Head circumference measurement


is 35.6cm or 14.0 in. Bowel sounds are present in all four quadrants. Newborn had first bowel

movement at 1200. Stool consistency and color are tary and black. Mom is breast feeding.

Feedings at 0500, 1200, 1300, and 1500. During the 1200 feeding newborn on right nipple for 15

minutes and 25 minutes on left nipple. “Breast-feeding infants should be fed when hunger cues

are displayed; rooting sucking on fists, clenched fists; these cues may be exhibited from 90

minutes to 3 hours after the last feeding; crying is the last sign of hunger” (Hogan et al. 2007, p.

276). There is sufficient evidence to confirm that women who breast feed have a reduced risk of

breast cancer, type 2 diabetes, cardiovascular disease, some cancers, postpartum depression, and

rheumatoid arthritis (Godfrey, 2010, p.1598). Client would like to breast feed for at least six

months postpartum. Anterior and Posterior Fontanels smooth and even. Eyes were aligned with

ears. Lungs are equally strong bilaterally. Reflexes are all intact and present. Reflexes we are

looking for include the

Babinski reflex- a neurological reflex where newborn toes will hyper-extend and fan

apart from dorsiflexion of big toe when foot is stroked upward from heel and across ball

of foot. Grasp reflex- elicited by placing an object in the newborn’s hand, resulting in a

firm hold of the object. Moro reflex-elicited by startling the newborn; flexion of thighs

and knees and fingers that fan, then clench as arms are thrown out, then brought together.

Rooting reflex- an infant’s tendency to turn head and open lips to suck when one side of

the mouth is touched. Sucking reflex- elicited by inserting a finger or nipple in newborn’s

mouth (Hogan et al. 2007, p. 266).

Clavicles are intact and there is Millia on newborns nose. “Tiny, white pustules on the face and

chin resulting from unopened sebaceous glands” (Hogan et al. 2007, p. 266). Testicles

descended. Cord care was performed every three hours. Skin warm and hug tag on. Safety check


completed for newborn. Safety check includes hospital tags on and bed is in locked position.

Suction bulb syringe in crib, and newborn is in nursery when mom is sleeping.

Conclusion

Clinicals permitted a student nurse to be on the floor for about eight hours. With this limited

amount of time it was difficult to include all aspects of patient care. Some aspects that were

omitted from this case study included the husband’s job and financial pressures that they may

experience with a newborn. Other topics not discussed were if the family is planning on having

more children in the future, birth control for mom or family arrangements including childcare

and education responsibilities. Ongoing care needs for client and newborn will be met by Lori

Penniks in Salem, Ohio.


Nursing Diagnosis: 1

Risk for infection related to open wound as evidenced by circumcision.

Goal: LTG: Appropriate healing with no evidence of infection by next appointment.STG: No evidence of infection by the end of my shift.

Interventions: 1. Intervention: Assess the circumcision site every 30 minutes for two hours (Davidson, 2008, p.876). Rationale: The circumcision needs to be assessed for any signs of infection. This includes increasing swelling, pus drainage, and cessation of urination (Davidson, 2008, p.876).2. Intervention: Apply petroleum ointment for the next few diaper changes (Davidson, 2008, p.876). Rationale: Applying petroleum ointment can help protect granulation tissue that forms as the glans heals (Davidson, 2008, p.876).3. Intervention: Scrub hands for 2 to 3 minutes from fingertips to elbows at the beginning of each shift, and wash with soap rubbing vigorously for 15 seconds before and after contact with newborn (Davidson, 2008, p.874). Rationale: Infection is best prevented by requiring that all personnel in direct contact with any newborn wash hands properly (Davidson, 2008, p.874). 4. Intervention: Assess for fever and irritability. Rationale: Infants with wound infection can show signs of fever and irritability (Gee, 1976, p.825).

Evaluation of Goal:

LTG: There was appropriate healing with no evidence of infection by on the baby’s next appointment.STG: There was no evidence of infection at the end of my shift.

EBP Citation: Davidson, M. R., London, M. L. & Ladewig, W. P. (2008). Old’s

Maternal-newborn nursing and women’s health across the lifespan

(8th ed.). Upper Saddle River, NJ: Prentice-Hall.

Gee, W. F., & Ansell, J. S. (1976). Neonatal Circumcision: A Ten-Year Overview: With Comparison of the Gomco Clamp and the Plastibell Device. Pediatrics, 58(6), 824. Retrieved from EBSCOhost.


Risk for ineffective breastfeeding related to inexperience with breastfeeding process as evidenced by gravida1, para 1.

Goal: LTG: Mother will report confidence in establishing satisfying, effective breastfeeding on next appointment.


STG: Mother will demonstrate effective breast feeding independently before discharge.

Interventions: 1. Intervention: Provide lactation education by reviewing the process of breastfeeding before next infant feeding time (Davidson, 2008, 923).

Rationale: Breastfeeding is not instinctive, it is learned. It is a natural process that takes know-how (Davidson, 2008, p.906) Providing the new mother with the support and information needed to prompt the immediate, invaluable, and demanding job of initiating milk production is essential for breastfeeding success (Godfrey, 2010, p.1598).

2. Intervention: Teach proper positioning and latch-on technique during next infant feeding ( Davidson, 2008, p. 925)Rationale: It is important to have the baby positioned properly in order to achieve an optimal latch-on attachment (Davidson, 2008, p.908).

3. Intervention: Provide breast pump instructions and review collection and storage before discharge (Davidson, 2008, p.924).Rationale: There are a number of different reasons for bottle feeding breast milk. All mothers have their own particular need (Davidson, 2008, p.910).

4. Intervention: Assess the progress of the breast feedings during each feeding (Davidson, 2008, p.910).Rationale: A systematic assessment of several breastfeeding episodes provides the opportunity to evaluate the mother’s needs (Davidson, 2008, p.910).

Evaluation of Goal:

LTG: Mother has reported confidence in establishing satisfying, effective breastfeeding at her next appointment.STG: Mother has demonstrated effective breast feeding independently before being discharged.




Godfrey, J. R., & Lawrence, R. A. (2010). Toward Optimal Health: The

Maternal Benefits of Breastfeeding. Journal of Women's Health

(15409996), 19(9), 1597-1602. doi:10.1089/jwh.2010.2290


Risk for imbalanced nutrition: Less than body requirements related to mothers increased caloric and nutrient needs status post-cesarean section as evidenced by emergency cesarean section due to non-reassuring FHR.

Goal: LTG: The infant will maintain appropriate weight on next exam appointment.STG: The infant will maintain daily nutritional requirements during stay.


Interventions: 1. Intervention: Provide information on maternal nutritional and fluid requirements before next meal (Davidson, 2008, p.924).Rationale: The mother needs a nutritional balanced diet with appropriate caloric and fluid intake to support breastfeeding (Davidson, 2008, p.923).

Breast milk does not reflect the mother’s precise diet; rather, it is naturally reformulated to meet the growing needs of the infant, including changes in the portion of macronutrients (e.g., proteins, carbohydrates, and fats) (Godfrey, 2010, p.1597).

2. Intervention: Review infant weight gain expectations during lactation education (Davidson, 2008, p.924).Rationale: If the newborn is not gaining sufficient weight the infants feeding history must be examined more closely (Davidson, 2008, p.922).

3. Intervention: Review infant input and output expectations during lactation education (Davidson, 2008, p.924).Rationale: Feeding requirements/caloric requirements are based on the infant’s birth weight. Output will reflect the input (Davidson, 2008, p.923).

4. Intervention: Encourage mother to maintain a feeding diary to monitor the infant’s intake and output during lactation education (Davidson, 2008, p.924).Rationale: A feeding diary can be available for the healthcare provider to review. This will aide in reviewing a feeding history during exam (Davidson, 2008, p.922)

Evaluation of Goal:

LTG: The infant has maintained appropriate weight on the next exam appointment.STG: The infant has maintained daily nutritional requirements during his stay.




Godfrey, J. R., & Lawrence, R. A. (2010). Toward Optimal Health: The Maternal Benefits of Breastfeeding. Journal of Women's Health (15409996), 19(9), 1597-1602. doi:10.1089/jwh.2010.2290


Risk for impaired parent-infant attachment related to barriers of attachment secondary to lack of privacy as evidenced by

Goal: LTG: Mother will have positive interactions with her baby that will be evident and reported at her next appointment.STG: Before the end of my shift the mother will understand and explain how important it is to have adequate bonding time.

Interventions: 1. Intervention: Keep hospital practices that inadvertently interfere with the attachment process to a minimal during my shift


(Davidson, 2008, p.899).Rationale: Parental-newborn attachment can be enhanced if the care providers keep routine investigations to a minimum (Davidson, 2008, p.674).

2. Intervention: Provide privacy and quiet time by talking in quiet tones and avoiding loud noises during my shift (Davidson, 2008, p.674).Rationale: The nurse plays a vital role in fostering parent infant attachment (Davidson, 2008, p.878).

3. Intervention: Review how the advantages of breastfeeding create and foster the development of the maternal infant bond (Davidson, 2008, p.900).

Rationale: Breastfeeding necessarily provides increased skin-to- skin contact for the mother-infant dyad when the infant's face touches the mother's breast. Skin-to-skin contact can improve affect and reduce anxiety (Else-Quest, 2003, p.498).

4. Intervention: Check the mother regularly for signs of fatigue while she is assuming responsibility (Davidson, 2008, p.1055).Rationale: Some women are eager to learn and easily feel overwhelmed (Davidson, 2008, p.1055).

Evaluation of Goal:

LTG: The mother had positive interactions with her baby that is evident and was reported at her next appointment.STG: Before the end of my shift the mother understood and explained how important it is to have adequate bonding time.




Else-Quest, N. M., Hyde, J., & Clark, R. (2003). Breastfeeding, Bonding, and the Mother-Infant Relationship. Merrill-Palmer Quarterly, 49(4), 495-521. Retrieved from EBSCOhost.

Mom’s Labs Lab Test Normal Value Preterm Value Postpartum Value

White blood cells 5000-10000 mm3 13.87 mm3 12.87 mm3Hemoglobin 12-16 g/ml 13.5 g/ml 9.7 g/mlHematocrit 37%-47% 38.8% 29.2%

Platelets 130,000-400,000 mm3 131,000 mm3 221,000 mm3

Taber’s cyclopedic medical dictionary, 2010

Other Lab’s


Test Normal Findings Patient ResultsType and Rh N/A A+VDRL/RPR NR NR

Rubella Immune Immune Urine C & S Negative Negative

Chlamydia/Gonorrhea Negative Negative PAP test Negative Negative

Old’s Maternal-Newborn Nursing, 2008

Babies Lab’s Lab Test Normal Value Result

pH 7.30 7.2 pO2 60-80 mmHg 12.5 mmHg

pCO2 35-50 mmHg 53.3mmHgHCO3 17-28 mEq 24.8mEqCO2 13-29 mmol/L 26.5mmol/L

Blood Glucose 45 or greater 75Old’s Maternal-Newborn Nursing, 2008

Medications Medication Action Normal Dose Route Nursing

Implications

Motrin

Inhibits prostaglandin

synthesis to reduce pain, fever, and inflammation.

200-400 mg every 4-6 hours

POMonitor pain and temperature frequently during administration.

Percocet Binds to opiate receptors in the central nervous

system to reduce pain.

5-10 mg every 3-4 hours

PO

Monitor frequently for pain and assess respiration, pulse,

blood pressure, and bowel function

during administration.

Antagonizes the effect of histamines 25-50 mg every 4-6 PO, IM, or IV Assess degree of


Benadryl to reduce allergic reactions.

hours allergic reaction

Ferrous Sulfate Used to prevent and treat iron deficiency.

120-240 mg/day in 2-4 divided doses

PO, IM, or IV

Assess bowel function. Avoid using antacids,

coffee, tea, eggs, or whole grain breads

within one hour after administration.

Davis’s Drug Guide for Nurses,2009

References

Davidson, M. R., London, M. L. & Ladewig, W. P. (2008). Old’s Maternal-newborn nursing and women’s health across the lifespan (8th ed.). Upper Saddle River, NJ: Prentice-Hall.

Deglin, JH., & Vallerand, AH. (2009). Davis's drug guide for nurses. Philadelphia, PA: F.A.

Davis.

Else-Quest, N. M., Hyde, J., & Clark, R. (2003). Breastfeeding, Bonding, and the Mother-Infant Relationship. Merrill-Palmer Quarterly, 49(4), 495-521. Retrieved from EBSCOhost.

Gee, W. F., & Ansell, J. S. (1976). Neonatal Circumcision: A Ten-Year Overview: With

Comparison of the Gomco Clamp and the Plastibell Device. Pediatrics, 58(6), 824.

Retrieved from EBSCOhost.


Godfrey, J. R., & Lawrence, R. A. (2010). Toward Optimal Health: The Maternal Benefits of

Breastfeeding. Journal of Women's Health (15409996), 19(9), 1597-1602.

doi:10.1089/jwh.2010.2290

Hasegawa, J., Matsuoka, R., Ichizuka, K., Kotani, M., Nakamura, M., Mikoshiba, T., & ... Okai,

T. (2009). Atypical variable deceleration in the first stage of labor is a characteristic fetal

heart-rate pattern for velamentous cord insertion and hypercoiled cord. Journal of

Obstetrics & Gynaecology Research, 35(1), 35-39. doi:10.1111/j.1447-

0756.2008.00863.x

Hogan, M. A. (Eds.). (2007). Maternal-Newborn Nursing: Reviews and Rationales (2nd ed).

New Jersey: Pearson Education, Inc. (Original work published 2003).

Olds, S. B., Davidson, M. R., Ladewig, P. W., & London, M. L. (2004).

Maternal-Newborn Nursing & Women’s Health Care. New Jersey: Pearson Education,

Inc.

Venes, D. (Eds.). (2005). Taber’s Cyclopedic Medical Dictionary(20th ed). Philadelphia: F.A.

Davis Company.


Tables

Table 1. Apgar Scoring System

Sign 0 1 2

Heart Rate Absent Slow-below 100 Above 100

Respiratory Effort Absent Slow-irregular Good crying

Muscle Tone Flaccid Some flexion of

extremities

Active motion

Reflex irritability None Grimace Vigorous cry

Color Pale blue Body pink, blue ext. Completely pink

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