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C.M. 24 y/o, G:1 P:1
O+, vaginal delivery, nka., Babyboy, M
male, born…
C.M. 24 y/o, G:1 P:1
O+, vaginal delivery, nka.
Respiratory: clear/unlabored breath sounds upon auscultation on all lung fields, breathing on RA.
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GI: abdomen soft, non distention noted, non-tender, bowel sounds present in all 4 quadrants. No bowel movements yet.
GU: voids frequently and independently, clear yellow urine, no odor.
Cardiovascular: normal heart sounds, radial pulse 64bpm, reg rate and rhythm, cap refill <2 seconds.
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NURSING DIAGNOSES: Ineffective breastfeeding r/t discomfort and difficulty latching on.
Goal: Patient will verbalize/demonstrate techniques to manage breastfeeding problems by end of shift.
Goal met: Patient demonstrated techniques to manage breastfeeding problems, and stated she would switch to formula if she wasn't able to breastfeed.
Reproductive: Breast: No masses upon palpation, nipples erect and full, fundus is midline 1cm below umbilicus. perineum is clean and intact, moderate bleeding as evidenced by padding. Lochia bright red, 1 pad, no clotting noted. 1 hemorrhoid noted in anal area.
INTERVENTIONS:
- Offered nurse/mother assistance with each feeding.
- Consult lactation nurse.
- Helped mother manually express a few drops of milk and feed them to the baby.
- Taught mother along with the nurse about bottle-feeding from my newborn teaching cards.
Complications during pregnancy:
- Tear of lateral meniscus of left knee
- Chronic idiopathic constipation
- Gestational (pregnancy-induced) htn
NURSING DIAGNOSIS: Anxiety r/t breastfeeding process and unable to breastfeed.
Goal: Patient will demonstrate decreased anxiety, and understand it's okay if she isn't able to breastfeed, by end of shift.
Goal partially met: Mother's anxiety did go down after talking to her, but noticed she still felt sad/disappointed.
INTERVENTIONS:
- Sat with patient and talked about how she felt.
- Provided adequate rest periods for mother.
**NURSING DIAGNOSIS: Readiness for enhanced knowledge on breastfeeding r/t lack of knowledge
Goal: Patient will verbalize understanding on tips to help get baby to latch onto breast/feed baby.
Goal met: Patient verbalized understanding on tips and demonstrated on what she was taught.
INTERVENTIONS:
- Put in consult with lactation nurse.
- Talked to patient about knowledge of breastfeeding, stated she has never attended classes but has seen her sister do it with her kids.
- Educated mother from my newborn teaching cards about "football" method position and sensation she might feel when baby latches on.
- Taught patient to observe baby for signs that they are ready to breastfeed such as sucking on their thumb.
- Psychological:
- lack of sleep
- knee still bothers patient, she needs help getting out of bed
- feeling fatigued from not being able to breastfeed baby
Cultural/family:
- Patient stated she has a strong support system: her boyfriend, mom and sister are present and her boyfriend is very "hands on and excited" about baby.
MEDS:
- Motrin 800mg
- 1 proctofoam rectal applicator
Skin: Skin color consistent throughout, no lesions noted throughout skin, aside from hemorrhoid in anal area, +1 pedal edema present bilaterally.
Babyboy, M
male, born 09/15, GA: 39(2), 6lbs 4oz.
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Respiratory: clear breath sounds in all lobes, no retractions, breathing unlabored
Skin: Pink throughout, warm and dry to the touch, baby is jaundice. no abnormal rashes or lesions noted. Overlapping sutures, fontanelles soft and flat. palpated clavicles, intact no signs of trauma.
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moist mucus membranes, palate intact, no tongue tie, no congestion noted.
Cardiovascular: heart sounds are normal, regular rhythm, 2+ brachial and femoral pulses. <2 capillary refills.
GI: positive bowel sounds upon auscultation, abdomen soft, non-tender, normal external genitalia,
suck and grasp reflex present, 2+ in upper and lower extremities.
NURSING DIAGNOSIS: Neonatal jaundice r/t age <7 days
Goal: • Baby will receive appropriate therapy to enhance indirect bilirubin excretion.
Goal met: Baby was put under phototherapy to help with jaundice which helped as his levels went down.
INTERVENTIONS:
- Assisted nurse in checking babies bilirubin levels.
- Assisted nurse in putting baby under phototherapy.
Other interventions from the book: Evaluate maternal and delivery history for risk factors for neonatal jaundice (RhD, ABO, G6PD deficiency, direct Coombs). Assessment of maternal and neonatal risk factors that may cause jaundice is important in the detection of neonatal jaundice (Perry et al, 2014).
NURSING DIAGNOSIS: Imbalanced Nutrition: less than body requirements r/t imbalance of glucose and insulin level
Goal: Baby blood glucose levels will rise within the next hours by the end of shift.
Goal met: Patients blood glucose levels did rise to 54 mg/dl.
INTERVENTIONS:
- Assisted nurse and mother in attempting to feed baby with breastmilk.
- Assisted mother with feeding baby with donor breastmilk.
- Assisted mother and nurse in feeding baby after hand expressing.
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MEDS:
- erythromycin 5mg both eyes
- Hep B 0.5ml injection
- Dextrose 40% gel 1.42 ml orally
Newborn care plan:
- treat hypoglycemia
- small for gestational age