Part I: Recognizing RELEVANT Clinical Data History of Present Problem: Sarah Daniels was born six hours ago by vaginal delivery after 22 hours of…

QuestionAnswered step-by-stepPart I: Recognizing RELEVANT Clinical Data  History of Present Problem:   Sarah Daniels was born six hours ago by vaginal delivery after 22 hours of labor at 36 weeks gestation because of premature rupture of membranes. She weighed 9 lbs 0 ounces. (4090 g). Her Apgar was 8 at one minute and 9 at 5 minutes. Her newborn assessment revealed a cephalohematoma on the right-posterior aspect of her head. All other assessment data is within normal limits. Sarah has breastfed once since birth for seven minutes. She is noted to be sleepy when at the breast and not an aggressive feeder, consistent with her gestational age. She has voided once since birth, but has not yet stooled. Sarah’s mom Morgan was a diet-controlled gestational diabetic. Morgan’s prenatal labs are as follows: Blood type is O +, GBS is negative, Hepatitis B is negative. Her prenatal course was unremarkable other than the premature rupture of membranes.  Sarah’s blood type is A+. Blood sugars were obtained per protocol starting at two hours after birth and have been consistently > 50 mg/dL. Her hematocrit was tested per protocol of a baby of a diabetic mother born before 37 weeks and was 48% four hours after birth. Twelve hours after birth, her transcutaneous bilirubin level is 6.1 mg/dL.  Personal/Social History: Morgan Daniels is a 22-year-old single mom who attends a local community college. The father of the baby is not involved. Morgan lives with her parents, who are supportive and available.  What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical SignificantRELEVANT Data from Social History: Clinical Significance:     Patient Care Begins: Current VS:   NIPS Pain Assessment: T: 98.3 F/36.8 C (axillary)  Facial Expression: Relaxed P: 138 (regular)  Cry: No cry R: 54 (regular)  Breathing Pattern: Relaxed   Legs: Relaxed   State of Arousal: Sleeping NIPS Score: 0  What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance:              Current Assessment: GENERAL APPEARANCE: Calm, body flexed, no grimacing, appears to be resting comfortably RESP: Breath sounds clear, nonlabored respiratory effort. No grunting, retracting or nasal flaring noted CARDIAC: Heart sounds regular with no abnormal beats, S1S2, brisk cap refill, no edema. Moderate systolic murmur present over apex. NEURO: Sleepy; difficult to wake for feedings, does not stay awake at breast. All reflexes intact INTEG: Facial jaundice noted, skin color pink with acrocyanosis. Cephalohematoma to right-posterior aspect of head. Swelling does not cross sutures lines.   RELEVANT Assessment Data: Clinical Significance:                Lab Results: Current: High/Low/WNL? Bilirubin (<5 mg/dL) 6.4    Hgb (15-24 g/dL) 18   Hct (45-65%) 60    Glucose (40-60 mg/dL) 55      What lab results are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT Lab(s):  Clinical Significance: TREND: Improve/Worsening/Stable:                   Part II: Put it All Together to THINK Like a Nurse! 1.      After interpreting relevant clinical data, what is the primary problem? (Management of Care/Physiologic Adaptation) Problem: Pathophysiology in OWN Words:            Collaborative Care: Medical Management 2.      State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies) Medical Management: Rationale: Expected Outcome: Obtain parental consent.  Check body temp hourly.  Place eye mask over Sarah's eyes.  Remove all clothing except for her diaper.   Place Sarah on the Bilibed and under the bili lights.  Accurate and strict I and O  Repeat serum bilirubin level in 6 hours after phototherapy is initiated.             Collaborative Care: Nursing 3.      What nursing priority (ies) will guide your plan of care? (Management of Care) Nursing PRIORITY:    PRIORITY Nursing Interventions: Rationale: Expected Outcome:                4.      What psychosocial/holistic care PRIORITIES need to be addressed for this patient?  (Psychosocial Integrity/Basic Care and Comfort) Psychosocial PRIORITIES:      PRIORITY Nursing Interventions: Rationale: Expected Outcome: CARE/COMFORT:      Physical comfort measures       EMOTIONAL (How to develop a therapeutic relationship):                 SPIRITUAL:             5.      What educational/discharge priorities need to be addressed to promote health and wellness for this patient and/or family? (Health Promotion and Maintenance)   Copyright © 2018 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. Health ScienceScienceNursingNUR MISCShare Question

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