Interrelatedness of Mother and Newborn: Historical Essay

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Current Hospitalization

The patient is a 391 one-day-old neonate who was born via c-section 09/09/2019 at 1109AM. The estimated delivery date was 09/16/2019. Apgar’s were 9/9. Baby weighed 3.775 kg and is 50.8 cm in length. Head circumference is 38.7 cm and chest circumference is 34.3 cm. Delivery was uneventful and no resuscitation efforts were needed.

Maternal History

Mother is single, Caucasian female, G3/T0/P1/A1/L1, with a history significant for preeclampsia and a fourth-degree perineal tear resulting in a rectovaginal fistula. Mother was only on prenatal vitamins throughout the course of her pregnancy. Mother had adequate prenatal care with routine visits to the same OB/GYN. There is no significant family history. Mother was GBS negative, Hepatitis B negative, Rubella immune, HIV negative and blood type A+.

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Complete Head to Toe Physical Assessment of the Neonate

At time of assessment, baby is resting comfortably in the bedside crib. Good activity and responsiveness to exam is present. Skin is pink, warm, and dry. Baby is normocephalic. No bulging or retraction of fontanelles upon palpation. No moulding of sutures. Eyes are symmetrical and in normal position. Ears are of normal shape and set. No nostril flaring present. Palate is intact both visibly and on palpation. Tongue is freely mobile. Chest has a normal contour with nipples at the mid-clavicular line. Breath sounds are clear bilaterally. Respiratory rate is 56. Heart rate is 160 auscultated apically. Heart sounds are normal without murmur.

Femoral pulses are strong and equal. Three vessel umbilical cord is present and clamped. Normal female genitalia present. Anus is patent. Back is symmetrical and spine is palpable along the length. NIPS pain scale is 2. NAS score is not applicable. 10 fingers and 10 toes are present with no evidence of malformation. Arms and leg are symmetric bilaterally and have normal position and good tone. Suck, grasp, Babinski, rooting, and startle reflex all present. Ballard score is 38. Baby is bottle-fed.

Laboratory and Diagnostic Studies

Newborn screens are state-mandated tests done to screen for abnormal conditions. According to the Indiana State Department of Health, all babies born in Indiana are required to have newborn screening done before they leave the hospital or within one week of birth if they are born at home.

Currently there are 3 different tests done on babies born in Indiana. The heel stick dried blood spot (DBS) test is done to screen for specific genetic conditions, the hearing screen is done to check the baby for hearing loss, and the pulse oximetry test is done to check the baby for critical congenital heart disease (CCHD) (“Newborn screening,” 2019).

A heel stick dried blood spot sample was collected on 09/10/2019 at 11:30AM. The results are pending as this is a send out test. A Universal Newborn Hearing Screen (UNHS) was performed at 3:50AM and the baby passed bilaterally. The pulse oximetry test for CCHD was performed at 11:45AM and the baby passed with a 100% in the right hand and 100% in the right foot. There were no other labs done on this baby.

The DBS screens for 13 different amino acid disorders, 2 endocrine disorders, 13 fatty acid oxidation disorders, 4 hemoglobin disorders, 14 organic acid conditions, and 5 other disorders such as biotinidase disorder, classic galactosemia, cystic fibrosis, severe combined

immunodeficiency, and spinal muscular atrophy. (“What conditions are screened for in Indiana?”, 2019). If babies have any of these disorders, they can get treatment and prevent serious health problems or developmental delays in the future.

The hearing test is done to screen for hearing loss. If detected early, it gives the parents time to learn how to best communicate with their non-hearing child.

The pulse oximetry test is done to screen for specific congenital heart defects that can be surgically treated or repaired shortly after birth. According to the CDC, specific CCHD conditions include, atrial septal defect, atrioventricular septal defect, coarctation of the aorta, hypoplastic left heart syndrome, pulmonary atresia, tetralogy of Fallot, total anomalous pulmonary venous return, tricuspid atresia, d-transposition of great arteries, truncus arteriosus, and ventral septal defect (“Specific congenital heart defects”, 2018). Undiagnosed babies can go into cardiac arrest and die, but if their conditions are caught before they leave the hospital, they can receive the care and treatment needed.

Nursing Diagnosis

The nursing diagnosis is the nurse’s response to potential health problems or complications of the medical diagnosis. The actual nursing diagnosis will state the current health problem such as impaired tissue integrity related to surgical procedure as evidenced by c-section incision. The potential nursing diagnosis will state what the patient could be at risk for because of their medical diagnosis such as risk for acute pain related to surgical incision.

Nursing diagnoses are used to identify potential problems or syndromes to be aware of so the nurse can provide safe, effective care to their patient. Nursing diagnoses are prioritized so urgent needs are taken care of first. Nurses follow ABC’s (airway, breathing, circulation). After biological and physiological needs are met, nurses can prioritize patient’s needs based on Maslow’s hierarchy of needs, where safety needs come next, followed by love and belonging needs, then esteem needs, and finally self-actualization needs.

Nursing diagnoses for this baby in order of prioritization, according to Maslow’s hierarchy of needs, include:

  1. Risk for impaired gas exchange related to fluid in lungs. This was chosen because this baby was delivered via c-section and is at a higher risk of transient tachypnea of the newborn (TTN), which is a condition where there is too much fluid in the baby’s lungs, or the fluid isn’t leaving the lungs fast enough. This causes the baby to breathe harder and faster to get enough oxygen into their lungs. C-section babies do not go through the normal hormonal and physical changes that vaginally delivered babies go through during labor resulting in poor expulsion of lung fluid on own.
  2. Risk for altered body temperature related to trauma of birth. This was chosen because of the potential for cold stress and heat loss during birth.
  3. Risk for imbalanced nutrition less than body requirements due to bottle feeding. This was chosen because baby is bottle fed and mother may not know adequate caloric intake needed for proper growth and development.
  4. Risk for infection due to open umbilical stump. This was chosen because the umbilical stump has not yet dried up and fallen off and could become infected if not cared for properly.
  5. Risk for Sudden Infant Death syndrome related to lack of knowledge regarding infant sleeping in prone or side-lying position. This was chosen because all babies are at risk for this and proper parental education is needed to avoid this condition.
  6. Risk for injury related to need for caretaking. This was chosen because the mother also has another child for whom she is the primary caretaker and she is unmarried and may not have an adequate support system in place to assist with care of both of her children.

Treatment Modalities

Pharmacologic

The assessed baby had no complications therefore no treatments were needed other than the standard treatments given to all newborns. A 0.5-inch ribbon of Erythromycin (ROMYCIN) 5mg/gram (0.5%) ophthalmic ointment was applied to each eye within one hour of birth. According to American Academy of Pediatrics Redbook (2018-2021), “a prophylactic agent of 0.5% erythromycin ointment should be instilled into the eyes of all newborn infants (including those born by cesarean delivery) to prevent sight-threatening gonococcal ophthalmia” (p. 1049). Hepatitis B vaccine (ENGERIX – B) 0.5 mL IM was given in the right thigh. The CDC recommends administering the first hepatitis B vaccine within the first 12 hours after birth. This is to reduce the risk of the baby getting hepatitis B from an undiagnosed mother or family member who may not know he/she is infected. Finally, the baby was given phytonadione (Vitamin K1) (AquaMEPHYTON) 1mg/0.5 mL IM. Babies are born with very little vitamin K stores; therefore, they are deficient. Vitamin K is essential for blood clotting and babies are at risk for potential life-threatening bleeding since they are deficient.

There are no known drug-drug interactions between all of the drugs given to the baby. In the case of a drug-drug interaction, the effects, of one or more of the given drugs, will either increase or decrease. These effects are usually adverse and undesirable. Therapeutic effects may be limited or there may be no effect at all. The nurse should be familiar with the mechanism of action of the medications he/she is administering. The nurse should also be familiar with any known contraindications of the medications he/she is administering. Nursing interventions include knowing the rights of medication administration, verifying the physician’s orders, knowing the desired effects and the side effects of the medication. The nurse must monitor the baby for therapeutic effects, side effects, or toxic effects and the nurse should know what to do in the event the patient experiences those adverse effects. Vitals must be monitored, and a physical examination should be done.

Nursing

During the stay, the baby had vital signs taken at birth, 5 minutes after birth, 30 minutes after birth, 1 hour after birth, then again at 1600 hours, before bath at 2040, after bath at 2050, at 0320 and at 0830. Vitals remained within defined limits. An assessment of neuro, chest, HEENT, cardiovascular, respiratory, skin, abdomen, and GU was performed at 1140, 1600, 2040, 0320, and 0830. Assessment was also within defined limits at each time it was performed.

The altered States of Health

Impaired gas exchange is defined by Ackley, Ladwig, & Makic (2017), as “excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane” (p. 404). Ignatavicius, Workman, Rebar (2018), further explain gas exchange as, “triggered by neurons in the brain sensing the need for gas exchange. These neurons stimulate contraction of skeletal muscles that expand the chest cavity, causing inhalation of oxygen-containing air into the airways and lungs. From the lung alveoli, oxygen diffuses into blood and red blood cells, and the waste gas carbon dioxide diffuses from the blood into the alveoli. Once in the alveoli, carbon dioxide is exhaled from the body as a result of recoil of lung elastic tissues and contraction of skeletal muscles that constrict the chest cavity (p. 20-21). Signs and symptoms of impaired gas exchange include abnormal blood gas results, abnormal breathing rate/depth/rhythm, confusion, cyanosis, irritability, nasal flaring, restlessness, and tachycardia.

The goal of a patient with this nursing diagnosis would be to have the patient remain free from signs of respiratory distress. Interventions include, measure Apgar’s as this would help determine the need for immediate intervention. Clear the airway slowly via nasopharyngeal suctioning while monitoring apical pulse during suctioning. Clearing the airway eliminates accumulation of fluid, facilitates breathing efforts, and prevents aspiration. The nurse should also dry off the baby and place a stocking head cover on to lower the effects of cold stress which can depress respiratory effort.

Risk for altered body temperature is defined by Ackley, Ladwig, & Makic (2017), as “vulnerable to failure to maintain body temperature within normal parameters, which may compromise health” (p. 875). Thermoregulation is regulated by self to maintain homeostasis. Thermoregulation is further explained by Osilla & Sharma (2019), as:

The hypothalamus, controls thermoregulation. If the hypothalamus senses external temperatures growing too hot or too cold, it will automatically send signals to the skin, glands, muscles, and organs more at risk temperature outside of normal range, cool, pale skin, increased heart rate, piloerection, slow capillary refill and shivering.

According to the Stavis (2019), “Neonates are prone to rapid heat loss and consequent hypothermia because of a high surface area to volume ratio”. Stavis (2019) goes on to explain that:

Neonates have a metabolic response to cooling that involves chemical (nonshivering) thermogenesis by sympathetic nerve discharge of norepinephrine in the brown fat. This specialized tissue of the neonate, located in the nape of the neck, between the scapulae, and around the kidneys and adrenals, responds by lipolysis followed by oxidation or re-esterification of the fatty acids that are released. These reactions produce heat locally, and a rich blood supply to the brown fat helps transfer this heat to the rest of the neonate’s body.

A goal for a neonate with this nursing diagnosis would be to remain free of signs of respiratory distress and cold stress. This can be accomplished by placing a stocking cap on the baby’s head, dry the baby with a warm blanket to reduce heat loss due to evaporation and conduction. Nurses need to warm objects that come into contact with the baby such as hands, stethoscope, and exam table. This will aid in avoiding cold stress. The nurse should also assess the baby’s core temperature and maintain a core temp of 97.6 F (98.5 F rectal).

Risk for imbalanced nutrition less than body requirements is defined by Ackley, Ladwig, & Makic (2017), as, “intake of nutrients insufficient to meet metabolic needs” (p. 615). Infants are particularly susceptible to imbalanced nutrition due to their high demand for calories and nutrients. Imbalanced nutrition can affect multiple systems and cause nutrient deficiency related conditions. A goal for the bottle fed infant would be to not lose more than 10% of its birth weight. This goal can be accomplished by monitoring the sucking and swallowing reflexes, meeting nutritional requirements with on-demand feedings, and ensuring adequate caloric intake to support growth.

Interrelatedness

This was a textbook, uncomplicated pregnancy for this mother. She states she had adequate nutrition during her pregnancy, took her prenatal vitamins, and moderately exercised. She has no chronic conditions which would affect her baby. She had a c-section because with her previous pregnancy, delivery caused a fourth-degree perineal tear and she wanted to avoid that complication with this delivery. She had preeclampsia with her previous pregnancy, but no incidences of high blood pressure at all with this pregnancy. Her c-section incision was a low-transverse incision, performed after successful administration of spinal anesthesia. There would be some concern about the medications administered during placement and management of the anesthetized patient, crossing the placental barrier and exposing the baby, possibly resulting in lowered Apgar scores, but this baby had Apgar’s of 9/9 so she was not adversely affected by any medications that may have crossed the placental barrier.

References

  1. Ackley, B. J., Ladwig, G.B., & Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). St Louis, MO: Elsevier.
  2. Ignatavicius, D.D., Workman, M.L., & Rebar, C.R. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. (9th ed., Vol. 1). St. Louis, MO: Elsevier Inc.
  3. Kimberlin MD, FAAP, D. W., Brady, MD, FAAP, M. T., Jackson, MD, FAAP, M. A., Long MD, FAAP, S. S., & (2018). Red Book 2018: Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics.
  4. Newborn screening. (2019). Retrieved from https://www.in.gov/isdh/27973.htm
  5. Oscilla, E. & Sharma, S. (2019). Physiology, Temperature Regulation. StatPearls Publishing. January 2019. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK507838/
  6. Specific congenital heart defects. (2018). Retrieved from https://www.cdc.gov/ncbddd/heartdefects/specificdefects.html
  7. Stavis PhD, MD, R., (2019). Hypothermia in Neonates. Merck Manual. Retrieved from https://www.merckmanuals.com/professional/pediatrics/perinatal-problems/hypothermia-in-neonates
  8. What conditions are screened for in Indiana? (2019). Retrieved from https://www.babysfirsttest.org/newborn-screening/states/indiana

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