Kerry, Kris, & Megan

 G2P2L2
 Baby girl
 7lb 6oz
 born may,25, 2011
 38wks 6 days gestation

Lab Data
Diagnostic Tests
Prenatal Medications

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 Blood Glucose- 116
 Sickle cell – no trait
 Syphilis-negative
 Hepatitis- positive for antibodies
 Vital signs- 36.9 88 20 112/66
 Blood type – A-

 Ultrasound
 16 weeks, showed size, structure, growth WNL
 Baby girl

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Prenatal vitamins- 1 tab daily to prevent risk of neural 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

 Cesarean birth
 IV running
 Monitored vitals for the mom and fetus

Head to Toe
Assessment
Laboratory Data
Medications and
Procedures
Nursing diagnosis

Time
0800
1200
1500
Time
0700
0800
1200
1300
Temp in C
36.8
36.9
36.9
Pulse
72
88
80
Pain Level
6-7
3
5
2-3
Resp.
16
20
16
Intervention
Motrin
Motrin
BP
122/66
116/70
120/76

 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
WBC
RBC
HGB
HCT
Platelets
Medications
RhoGam
Ferrous Sulfate
Multivitamin
Lanolin
Motrin
Pt. Values
8.16
3.39
8.2 g/dl
32.2%
174
Dosage
20 mcg IM
325 mg
1 tablet
Topical
600 mg
Normal Value
5-10
4.2-5.4
12-16 g/dl
38-47%
150-450

 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 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 pH
Pco
2
Po
2
HCO
3
-
Norms
7.23 – 7.33
40.6 – 57.4
11.8 – 24.2
19.5 – 24.5
Patient results
7.312
50.2
12.4
28.4
Analysis
With in Normal Limits
(WNL)
WNL
WNL
Metabolic Alkalosis

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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)
 Action: required for hepatic synthesis of blood coagulation
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 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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