Student initials: RMS

Date(s) of care: 05/31/08

Patient Information
Pertinent Medical History: Baby L was born 05/28/08 @ 11:18. Delievery CS for breech. Initial Assessment: weight was 6 lb, 5 oz.
(@0015, 05/31) length- 18.25” HC- 13.25”T-98.1F, resp-54; HR-66. Baby active; color is pink with olive undertones, good cry,
head normocephalic,fontanelles and sutures WNL.Milia present across nose. Hair is soft, black and sparse. Eyebrows and lashes
present, eyes and ears level, nostrils equal, no flaring observed. Sucking pads present. Palate intact, good suck reflex. Eyes
bright dark brown, + blink reflex, baby is responsive to sound and movement. No drooping or paralysis noted in face. Scelera
bluish-white. Ears are symmetrical, well-formed. No lesions noted. Clavicles straight and intact. BL lung expansion, Lungs clear
BL, nipples symmetric, flat. HR regular, no murmurs or thrills noted. Abdomen protruding, umbilical cord dry, no bleeding. Active
bowel sounds x 4 quad. No inguinal bulges, femoral pulses +1/4. Genitals symmetrical; pubis dark brown and engorged, scant
smegma present within labia. Buttocks symmetric, anus patent, no dimpling at coccyx. Symmetric buttock creases. All reflexes
charted as present. Apgar 8/9.
Occupation: newborn baby
Family History: FOC not present, great-grandmother has band.
Educational Level: none
Religion: none; mother is Baptist
Medications: none
Sociocultural considerations: family is of low socioeconomic status; may need referrals to outside agencies
ALLERGIES: NKA
Current lab findings: blood Type B+
DNR status: full CPR
Current diagnostic findings: normal, healthy newborn
 Assessment Nursing Diagnosis Goals & Expected Outcomes Nursing Interventions Rationale for interventions Evaluation
(Supporting data) (NANDA diagnostic statement) (Realistic, timed, measurable) (Strategies or actions for care) (Include source and page numbers) (Client’s response to nursing actions
& progress toward achieving
goals & outcomes)
Subjective: Baby is calm, Assess infant’s temp each Infants lack mature
soothes easily, does not Risk for imbalanced Infant will maintain its hour thermoregulation. Temps too high Goal Met: Baby L’s temp. remains
appear uncomfortable body temperature r/t body temperature between or too low can disrupt acid-base WNL for entire shift
97.0 and 99.0F for entire balance, causing seizures or
extreme of age (newborn shock.1
status) shift
If temp is above 101F, take Infants are at risk for febrile
measures to bring temp to seizures r/t immature
normal range: thermoregulation and must be
o Administer safeguarded against further
Objective: Baby L’s axilla antipyretics as sequelae.2
temp: 98.1 F; skin warm and ordered
dry Signs of neonatal seizures
o Monitor and
include:
document related
symptoms with
specific regard to • Repetitive sucking
febrile seizures • Repeated extending of the
tongue
• Continuous chewing
• Continuous drooling
• Long pauses in breathing
(apnea)
• Rapid eye movements
• Blinking/fluttering of eyelids
• Fixation of gaze to one side
• Body aligned to one side
• Pedaling/stepping
movements of legs
• Paddling/rowing movements
of arms

• Rapid muscle jerks 3

1
Cox’s Clinical Applications of Nursing Diagnosis; pg.141
2
Cox’s; pg.141
3
http://www.epilepsyfoundation.org/infants/neonatalonset.html
 If temp is < 97.0F, take
measures to bring temp to
normal range:
o place Young infants cannot initiate
infant compensatory regulation of
under temperature and can become
warmer septic at body temps below 97.0F
4

Infants can become dehydrated

o or on under warmer if not carefully
monitored.5
mother’s
chest
under
blanket

Assessment Nursing Diagnosis Goals & Expected Outcomes Nursing Interventions Rationale for interventions Evaluation

4
Old’s Maternal and Newborn Nursing; pg.
5
Cox’s; pg.141
 (Supporting data) (NANDA diagnostic statement) (Realistic, timed, measurable) (Strategies or actions for care) (Include source and page numbers) (Client’s response to nursing actions
& progress toward achieving goals
& outcomes)
Subjective:
MOC states “I have no milk Ineffective Assess a feeding for proper Collect baseline data Baby L was able to consume 20mL
because I had a c-section”; Baby will feed four times technique during four feedings
MOC is using S&S to breastfeeding r/t during shift,
supplement feedings. maternal breast supplementing with 20 Determine effect of altered Maternal-infant response
anomaly AEB need for mL of formula per feed breastfeeding pattern on provides important
supplemental feedings mother and infant by information in determining
Objective:
and no observable spending 30 minutes talking how serious the breastfeeding
maternal milk with mother. Observe issue is. This will dictate how
Baby L is consuming 20-30 mL production mother-infant interactions to approach the problem and
of formula per feeding; MOC’s and maternal feelings promote realistic follow-up.6
breasts are very tubular in expressed.
shape, very little mammary
tissue present; cannot express
milk with pump. Baby’s weight Measure I/Os
has remained constant since
birth (6 lb, 5 oz)

6
Cox’s; pg. 149
Assessment Nursing Diagnosis Goals & Expected Outcomes Nursing Interventions Rationale for interventions Evaluation
(Supporting data) (NANDA diagnostic (Realistic, timed, (Strategies or actions for care) (Include source and page (Client’s response to nursing actions
measurable) numbers) & progress toward achieving goals
statement) & outcomes)
Subjective:
Baby will remain free from Monitor vital signs every 4 Provides baseline and allows for Baby L remained free from infection
infection for duration of hours quick identifications of any
Risk for infection R/T hospital stay. deviations that could indicate
maturational factors and infection7
immature immune system
Institute aseptic precautions, Protects baby from pathogens
especially handwashing, around
Objective: infant.

patient is 3 day old infant

Teach MOC about infectious MOC was able to verbalize the

MOC will verbalize process, including routes, Provides basic knowledge for importance of proper handwashing
measures to decrease pathogens, environment and protecting newborn
infection in her newborn by host factors. Include specific
end of shift aspects of prevention:
• Wash hands often,
especially before
handling infant or
after changing her
diaper
• Do not allow sick
friends or family to
interact with infant

7
Cox’s pg. 54