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Medical Diagnoses: Ineffective breathing pattern r/t inadequate pulmonary development, Ineffective thermoregulation and Imbalanced nutrition


University

School of Nursing

N-347 Clinical Assessment Worksheet

Student     Date of Care 10/18    Worksheet # 2

 

Demographic Information

Health History

Care Prescriptions

Age: 17 days

Chronic Health Conditions & Previous Health Problems:

Diet: TPN w/ 2.5cc continuous

Gender: Female

Race: Caucasian

n/a

Activity:

 

Code Status:                              

IsolationS

Weight:

1 lb 6.58 oz

Height:

1 ft 1.19 in

 

IV Access:     saline lock               X continuous

Reason for Admission [patients own words]:

n/a

 

 Solution: amino ac/electrolytes, fat emulsion 20%

 

 

 Rate: rate unknown

 

 

Previous surgeries:                    [type & year]

None

I & O:  X voiding   Foley catheter   NG tube 

        

Medical Diagnosis [medical terms]:

premi 22 5/7 wks

 

Wound Care:

 

 

drains (Type, Location, Drainage from]

 

 

 

Pulmonary care:

Date of admission: 10/1 at 2009

 

Medical Complications:               

 

 

    X O2   _____ L/min  via   N/C     mask   

Surgery:                                                 Date:

None

 

    IS q ___ hrs.     MDI   HHN         

 

 

 

Nursing Diagnoses (3 - prioritized)

1. Ineffective breathing pattern r/t inadequate pulmonary development secondary to prematurity aeb opacities in bilateral lungs shown on x-ray suggesting surfactant deficiency disease, patient born at 22 5/7 weeks gestation.                            

    Med. albuterol atrovent 

            other _____________

Allergies: NKA

2. Ineffective thermoregulation r/t lack of subcutaneous fat secondary to prematurity aeb low birth weight and lack of

Glucometer:      ac & hs

 

subcutaneous fat stores, gestational age 22 weeks, current weight 0.640kg.                                                  

                       sliding scale insulin

 

3. Imbalanced nutrition, less than body requirements r/t absent

Other: endotracheal ventilation w/ INO

Discharge Plan Needs: parent education

sucking reflex secondary to preterm birth aeb TPN.                    

 

Describe pathophysiology of primary illnesses (acute and chronic)  Premature birth refers to birth before 37 weeks of gestation.  Preterm birth may result from preterm labor, spontaneous or induced, or may be by planned cesarean section for maternal or fetal complications.  Epidemiologic studies of preterm labor vary in terms of categorization, but generally, labor before 24 weeks is considered previable; before 28 weeks, extremely preterm; at 28 to 31 weeks, very preterm; and at 32 to 36 weeks, mildly preterm (Polin, Fox, & Abman, 2011).  According to this, this case in considered previable.  The patient was born at 22 5/7 weeks via vaginal delivery to a 28 year old woman G1P1 who went into preterm labor with bleeding.  Diffuse hazy opacities are present in bilateral lungs, consistent with evolving surfactant deficiency.  This is reported in the radiology report from a sing AP view of the chest performed on 10/18. 

 


Medications

Name

Action

Major Side Effects

Nursing Implications

Caffeine Citrate INJ

6mg q24hr/schiv syr

Start 10/2

Methylxanthine that stimulates CNS, relaxes cardiac muscle, promotes dieresis

Irritability, feeding problem symptom, acidosis, gastritis, hemorrhage, renal failure

monitor serum glucose, monitor s/s necrotizing enterocolitis, s/s caffeine induced toxicity (tremors, tachypnea, seizure, vomiting)

Amino acids/ electrolytes

1 bag continuous IV

Nutritional supplement, protein substrate

Fever, thrombophlebitis, edema, flushing, nausea, metabolic acidosis, thrombosis

Monitor laboratory values.

Fat emulsion IV 20%

1 bottle continuous IV

Nutritional supplement, lipids

Fever, pressure over eyes, nausea, vomiting, dyspnea, cyanosis, diaphoresis, hepatomegaly, splenomegaly, thrombocytopenia

Monitor improvement in clinical condition, lipid profile, blood coagulation, hepatic function, platelet count, serum electrolytes.  Monitor triglyceride, plasma free fatty acid levels.

Mupirocin 2% nasal

Oin to each nabid/ sch topical

Start 10/17

End 10/22

Antibacterial, topical, antibiotic

May interfere with other nasal drugs, pruritis, sensation of burning of skin

Monitor clearing of infected skin, monitor for sensitivity or local irritation.

Vitamin A inj

5000IUnit M/W/F @2IM

Start 10/1

Stop 10/29

Essential for normal function of retina

Hypervitaminosis A, fatigue, malaise, anorexia, vomiting, jaundice, drying/cracking of skin, arthralgia, thickening of bone, hepatosplenomegaly

Monitor improved ski disorder, monitor symptomatic improvement, monitor vitamin A level (normal 80-300units/mL)

Fluconazole Pediatric

3.6mg q48h/schiv

Start 10/2

End 11/13 taper

Antifungal, inhibits fungal cyochrome P-450 (responsible for fungal sterol synthesis), weakens fungal cell walls

Headache, dizziness, nausea, vomiting, dyspepsia, leukipenia, thrombocytopenia, rash, anaphylaxis

Monitor lab values esp. bilirubin, ALT, AST, platelet, WBC. Monitor hydration status.

LAB VALUES/TEST RESULTS

 

a.   Important lab tests to monitor              Why? (Consider diagnosis, pre-existing conditions,  medications, complications, etc)                                          

Glucose

Patient on TPN

ABGs

ABGs reflect mild/moderate acidosis, sepsis, or prolonged respiratory difficulties.

WBC

Signs of infection

 

 

 

 

 

 

 

b.      Hematology        Normal values             Patient’s Values (include serial labs)                                         Significance for this patient                                                                               

 

 

Date 10/15

Date 10/17

Date 10/18

 

WBC

8.0-14.3

20.20 H

20.78 H

23.29 H

Important to detect bacterial disease or infection

         Bands

 

n/a

n/a

n/a

 

         Segs

 

n/a

n/a

n/a

 

Plt

234-346

172

170

220

Coagulation, detect thrombocytopenia

Hgb

12.7-18.3

10.8 L

12.6

11.7 L

Can be used to indicate infection, anemia, oxygen, dehydration

Hct

37.4-55.9

31.2

35.8

33.3

Can be used to indicate infection, anemia, oxygen, dehydration

RBC

3.4-5.4

3.60

4.27

3.95

anemia

 

c.      Chemistry          Normal values             Patient’s Values (include serial labs)                                          Significance for this patient

 

 

Date 10/15

Date 10/16

Date 10/18

Renal failure, drug interactions

K+

4.5-7.2

4.9

4.7

4.9

Determine hydration status, cardiac failure, liver failure

Na+

133-146

144 H

144 H

141

Hydration status, renal failure, respiratory alkalosis

Cl-

96-111

113 H

112 H

108 H

Indicative of electrolyte imbalance, changes suggest losing/retaining fluid

CO2

17-31

20

21

23

Reflects increase in HCO3, respiratory acidosis

BUN

5-17

28 H

28 H

33 H

Renal function

Cr

0.2-1.0

0.6 H

0.6 H

0.6 H

Renal functional impairment

Glucose

20-80

71

73

69

Hyperglycemia, hypoglycemia

Albumin

2.6-3.6

3.1

3.2

3.2

Low albumin indicator of poor nutritional status, also moves calcium and medications through blood

 

d.      Coagulation       Normal values             Patient’s Values (include serial labs)                                          Significance for this patient

PT

 

n/a

 

 

 

INR

 

n/a

 

 

 

PTT

 

n/a

 

 

 


e.      Urine                     Normal values             Patient’s Values (include serial labs)                                      Significance for this patient

Color

 

n/a

 

 

 

Appearance

 

n/a

 

 

 

Spec. gravity

 

n/a

 

 

 

PH

 

n/a

 

 

 

Glucose

 

n/a

 

 

 

Ketones

 

n/a

 

 

 

Nitrates

 

n/a

 

 

 

RBCs

 

n/a

 

 

 

WBCs

 

n/a

 

 

 

Casts

 

n/a

 

 

 

Protein

 

n/a

 

 

 

 

 

f.       ABGs                     Normal values              Patient’s Values (include serial labs)             Significance for this patient

 

 

Date 10/16

Date 10/17

Date 10/18

 

pH

7.18-7.50

7.26 L

7.23 L

7.24 L

Acid-base balance

PaCO2

27-40

50 H

57 H

55 H

Ventilation of pulmonary function

HCO3

17.2-23.6

22 L

23 L

23 L

ABGs reflect mild/moderate acidosis, sepsis, or

PaO2

50-70

32 L

40

39 L

prolonged respiratory difficulties.

SaO2

85-90

64.0 L

80.0 L

63.9 L

 

 

g.      Other                      Normal values              Patient’s Values (include serial labs)             Significance for this patient

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


 

h. Pertinent x-rays or radiological studies Port chest 1 view, single frontal view of chest on 10/15. Single AP view radiograph of the chest was performed.  The right approach PICC line tip is in the expected topography of the lower SVC.  The ET tube is in satisfactory position.  The GI tube has been removed.  Cardiac size is normal.  Diffuse hazy opacities are redemonstrated in bilateral lungs, consistent with evolving surfactant deficiency disease among other possibilities of superimposed edema/infection.  There is interval decreased lung aeration.  No definite pleural effusion or pneumothorax are seen.  Other x-rays have been done on this patient since admission on 10/1, however not able to access during observation on 10/18.

 

i. Other (e.g. EKG / telemetry) Not able to access.

 

 Assessment of Patient

 

 

History of present illness: Patient was born at 22 5/7 weeks, vaginal delivery.  Patient’s mother went into preterm labor with bleeding.  Patient intubated, reintubated at 3 minutes.  Received curosurf X1 in delivery room.  Patient initially on conventional vent, switched to HFV, sats initially remained in the 60’s.  While umbilical lines being placed, HR started to decline, going as low as 38 with sats of 17.  Patient received NS bolus X3, HCO3 bolus X2, EPI X2, PRBC X1, FFP X2, 2nd dose curosurf given, 2nd bili light started.  10/3 PRB’s X2.  10/4 bicarb X2.  10/6 Plts, 2nd bili light discontinued.  10/7 umbilical lines discontinued, peripheral PICC inserted to left scalp, extubated twice during PICC insertion.

 

VS:    @ 2000    BP 67/46           HR  158            RR  49              O2 sat  71         Temp  98.4

 

Neuro / Musculoskeletal Activity (Movement, Strength, Sensation): Patient was still for most part.  When diaper being changed, patient would close legs together and bring them up toward belly.  Strength not assess.  Patient was able to sense touch, moved extremities when being cared for.  Nurse stated that mother held baby for first time yesterday and when she did all of baby’s vital signs improved especially O2 sats.

 

Skin (CUSPS/4Ts): Patient’s skin dry, smooth, and intact.  Patient’s skin warm because in isolette.  Skin turgor and tenderness not assessed.  Skin color was even throughout.  Patients skin somewhat transparent, no ulcerations, no swelling, no pitting edema, no scarring.

 

Cardiac (Heart Sounds, Rate & Rhythm, Capillary Refill, Radial & Pedal Pulses): heart regular rhythm, rate high at times.  No murmur.  Nurse stated capillary refill, radial and pedal pulses present. 

 

Pulmonary (Lung sounds, Rate, Rhythm, Effort): Nurse stated patients lung sounds clear after suctioning.  Patient on edotracheal ventilation with INO.

 

GI / Nutritional Status (Diet, Weight, Bowel Sounds, Abdomen-Flat/Distended & Soft/Firm, Last BM):  Patient on TPN.  10/18 change to continuous feeds at 2.5mL/hr.  Feeds increased by 0.5mL q24h at noon to goal of 4mL/hr.  Patient weights 0.640kg.  Abdomen flat and soft.  Last bowel movement 10/18.  Diaper changed at 2000.

 

GU/Reproductive (Urine Color and Amount, Menses for Women):  Patient’s urine pale clear yellow.  Nurse stated 11cc at 2100. 

 

Psychosocial: Nurse stated patient’s mother visits often.  Patient’s mother held her for first time 10/17. Patient tolerated well.

 

Learning Needs: Parent teaching.  Knowledge deficit: home care of premature infant related to lack of previous experience or teaching.

 


Date/Time

Nurses Notes

10/18 0800

Patients diaper changed.  Brown stool present.  Nurse did initial assessment.   

 

 

 

 

 

 

References

 

Board, R. & Wenger, N.R. (2003). Stressors and stress symptoms of mothers with children in the PICU. Journal of Pediatric Nursing, 18, 195–201.

Johnson, A. (2005). Kangaroo Holding Beyond the NICU. Pediatric Nursing, 31(1), 53-56.

 

Newfield, S. A., Hinz, M. D., Tilley, D. S., Sridaromont, K. L., & Maramba, P. J. (2007). Cox's Clinical Applications of Nursing Diagnosis (5th ed.).        Philadelphia, PA, USA: F.A. Davis Company.

Polin, R. A., Fox, W. W., & Abman, S. H. (2011). Fetal and Neonatal Physiology (4th ed.). Philadelphia, PA, USA: Elsevier Saunders.

 

Turan, T., Basbakkal, Z., & Ozbek, S. (2008). Effect of nursing intervention on stressors of parents of premature infants in neonatal intensive care                 unit. Journal of Clinical Nursing, 2856-2866.

 

 

 


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