Patient NB is a 21 year-old G1T0P1A0L1. NB delivered a baby girl at 33.1 weeks gestation on 5/3/2011. Her LMP was on 09/13/2010. Her estimated due date was 6/20/11. She is five feet four inches and her weight at delivery was 153 pounds. Her prenatal labs include an ultrasound on 2/11/11 and an AFP, which was not elevated. Her delivery was complicated with preterm labor. She arrived at the hospital completely effaced and 4cm dilated. Delivery was eminent, and at 1219 on 5/3/2011 she delivered her preterm baby girl vaginally. She had an epidural with fentanyl 15 ml/hr for pain relief, and suffered a superficial bilateral vaginal tear from the delivery. Her uterus has remained contracted. Her lochia is rubra small. She does not have a significant history as this is her first pregnancy and delivery. Patient denies drug and alcohol use. Patient denies smoking. She has no history of depression. Her husband is in the military and is stationed in Iraq, but he was able to get discharged for 1 week for the delivery. Patient will be staying with parents in IL, for a few weeks, until the baby is stable and discharged. She will than return to Kansas City, where she lives. In Kansas, she does not have family and has only a very small support system.
NB was18 hours post-delivery. Her main concerns at this time were afterbirth pains, especially after pumping and breast pumping instructions. Her baby was premature and was in the NICU, so she was pumping breast milk for the baby. Upon doing her assessment her vitals were as follows: T 98.7, P 88, R 14 and BP 118/72. Her uterus is well contracted, midline, and the fundus is 1cm below her umbilicus. Her lochia is rubra and she complains of after pains. Her breasts were soft but slightly engorged with nipples erect without redness; she is voiding large quantities with each void without discomfort or burning. Her perineum was very slightly swollen and she did have a normal bowel movement on 5/3/11. Her homan’s sign is negative. The baby was being cared for in the NICU, and she appears to be in good spirits as her husband is arriving from Iraq.
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Baby girl B is a preterm infant delivered via vaginal delivery at 33.1 weeks gestation. The mother went into preterm labor and delivered baby B on 5/3/11 at 1219 weighing 2270 grams and 17.75 inches. The position was LOA at birth. Her APGAR was 5 and 8 at birth. She had nuchal cord x1. Bulb and mechanical suction was used at birth as well as tactile stimulation. She was given free flow O2, PPV 100% at birth. Molding, Caput was noted at birth. She also had poor respirations and bradycardia at birth. There was no meconium at birth. She was given vitamin K and Hepatitis B vaccine at birth as well as erythromycin ointment. At birth she was diagnosed with respiratory distress syndrome.
She is now 18 hours old and in the NICU, she is being fed through the NG tube and she is also receiving total parenteral nutrition. She is under the warmer, has an umbilical arterial line, naso gastric tube for feeding, blood pressure cuff on left foot. Her medications via IV include multivitamins, neotrace, heparin, cysteine HCL, Gentamycin, TPN at 85ml/hr, CA gluconate, and cysteine HCL. Her vitals are heart rate 126; SO2 is at 95%, respirations 45, temperature 36.5. She is coombs negative. Chest X-Ray did indicate diffuse hazy lung opacity which indicates possible surfactant deficiency. In the NICU, the concerns for this baby are her lung immaturity as well as possible complications from her immaturity including: apnea, bradycardia, infection, jaundice, intraventricular hemorrhage, maintaining body temperature, immature gastrointestinal system, anemia or sepsis. “The NICU is designed to provide an atmosphere that limits stress to the infant and meets basic needs of warmth, nutrition, and protection to assure proper growth and development.” (Alabsi, 2010)
... a war veteran with 'scrape metal wounds'. Results: Preoperatively, patients' levels of pains were at an average of 8. 6 out of ... determine whether leeching procedures would affect patients with chronic pain, and by what amounts. These were patients aged from 13 to 96 that ... faded and 80 percent reduction of pain which allowed her to walk again 'pain-free'. The third patient, a 52-year-old, had ...
Priority nursing diagnosis for mother:
Acute pain related to postpartum physiologic changes AEB patient complaints of “pain”. She stated that she has moderate cramping, which became worse after pumping her breasts. Patient was grimacing after pumping, from cramps. She also complained of pain from her vaginal tears.
Priority nursing diagnosis for baby:
Ineffective breathing pattern related to surfactant deficiency AEB respiratory distress at birth. Baby’s apgar scores were 5 and 8 due to color and respiratory distress. The baby had bulb and mechanical suction, tactile stimulation and free flow oxygen. X-ray revealed surfactant deficiency.
I arrived at my maternal diagnosis of “pain”, because this was her chief complaint on this day. She complained of “cramping pain” on assessment, pain medication was given with relief noted. The patient also stated that “cramping got worse after breast pumping”. Her cramping is a called afterbirth pains. Her pain is a result of involution of her uterus. Involution is “the return of the uterus to a nonpregnant state after birth”, “this process begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle”. (Lowdermilk, 2006) Involution of the uterus is normal and desirable. “Breastfeeding and exogenous oxytocic medication usually intensify these afterbirth pains because both stimulate uterine contractions.” This explains why her cramps are intensified after pumping. “Oxytocin is the other hormone essential to lactation. As the nipple is stimulated by the suckling infant (or breast-pump), the posterior pituitary is prompted by the hypothalamus to produce oxytocin. This hormone is responsible for the milk ejection reflex.” (Lowdermilk, 2006) Oxytocin is the same hormone that stimulates uterine contractions during labor. I believe that this patient’s pain is the priority for multiple reasons.
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It is our responsibility as nurses to keep our patients pain free as much as possible. Pain is the fifth vital sign, and it is important to control this pain before it gets unbearable for the patient. Pain management is especially important to this patient as her baby is in the NICU. We do not want her to become discouraged, because of the pain. Breast milk is the ideal food for preterm infants, with benefits that are unique. “Breast milk proves neurocognitive outcome. It also decreases the risk of necrotizing enterocolitis. Greater physiologic stability occurs with breastfeeding as compared with bottle feeding”. (Lowdermilk, 2006) She would benefit with teaching techniques in pain management as well as the profound benefits of breast feeding her preterm infant.
I arrived at the nursing diagnosis of ineffective breathing pattern for this baby, as this is the primary concern for this preterm infant. She was diagnosed with respiratory distress syndrome, and chest x-ray revealed possible surfactant deficiency. Respiratory distress syndrome occurs in infant’s lungs that have not yet fully developed. “The disease is mainly caused by a lack of a slippery, protective substance called surfactant, which helps the lungs inflate with air and keeps the air sacs from collapsing. This substance normally appears in mature lungs.” (Lowdermilk, 2006) The symptoms of RDS usually appear within minutes of birth, although they may not be seen for several hours. Symptoms may include: Bluish color of the skin and mucus membranes (cyanosis), apnea, decreased urine output, grunting, nasal flaring, puffy or swollen arms and legs, rapid breathing, shallow breathing, shortness of breath, and grunting sounds while breathing, and unusual breathing movements. In the NICU she is receiving around-the-clock care from health professionals who specialize in caring for premature infants’. The treatment for RDS is supportive. “Adequate ventilation and oxygenation must be established and maintained in an attempt to prevent ventilation-perfusion mismatch and atelectasis”. (Lowdermilk, 2006) Her acid-base balance is evaluated by monitoring her ABG levels via her umbilical artery catheter. Her pulse ox monitors and documents her ventilation and oxygenation.” Fluid and nutrition must be maintained for the infant with RDS”. (Lowdermilk, 2006) She is receiving TPN 8.5ml/hr. “Parental nutrition can provide protein and fat to promote a positive nitrogen balance.” (Lowdermilk, 2006) Her hydration is assessed daily by monitoring electrolytes, urine output, specific gravity, and daily weights. Her treatment also includes surfactant replacement, breathing support, oxygen therapy, and supportive and preventative medications.
... use so called electronic breathing monitors, which alarm the adults when baby stops breathing for some time. Such ... on it is firmly improving.Bibliography:"Facts Abut Sudden Infant Death Syndrome." SIDS Network.CAM Consulting. 19 Mar ... . It is very important to take care about the baby, to hold him, to spend a ... . Death happens very fast and babies do not suffer any pain or struggling. For the decades ...
Acute pain related to postpartum physiologic changes AEB patient complaints of “pain”. Interventions: Assess location, type and quality of pain to direct intervention, Explain the source and reasons for the pain, its expected duration, and treatments to decrease anxiety and increase sense of control, administer prescribed pain medications to provide pain relief. The source of pain is “cramping”, and it got worse with breast pumping, so I taught her to take her pain medications before pumping to decrease some of the pain that results from pumping. I also advised her to take medications before the pain gets to bad and unmanageable.
Ineffective breathing pattern related to surfactant deficiency AEB respiratory distress.
1. Position neonate in prone position
2. Suction nasopharynx and trachea as necessary to remove mucus or secretions
3. administer oxygen and monitor neonatal response to maintain oxygen saturation.
4. Maintain a neutral thermal environment to conserve oxygen and glucose.
5. Monitor ABG levels, acid-base balance, oxygen saturations, respiratory rate and pattern, breath sounds and airway patency; observe for grunting, nasal flaring, retractions, and cyanosis to detect respiratory distress.
Analysis of Outcomes
I feel that the articles and textbook were very relevant in planning care for this baby. According to the textbook, the care of this preterm infant is supportive and preventative. The plan of care suggested in the literature coincides almost exactly with the care being provided at LCMH. Having said that, great care was provided and as a result some improvements were seen in the baby’s condition. The Doctor decided to start weaning the baby off of oxygen. She was also showing improvement in maintaining her temperature. According to the literature, usually a preterm infant is ready for discharge around his or her estimated due date. Before this is possible for the baby she will have to be able to maintain adequate nutrition, and be able to breast feed without distress. She is not ready to go home yet, but she is on the right pathway as of right now.
... interventions, if the patient develops tolerance. Referral to a pain specialist - If the nurse clinician can no longer provide ... ”. WHO (2003) further states that palliative care: • provides relief from pain and other distressing symptoms; • affirms life and ... active curative care to palliative care (with comfort care and symptom management) requires that care team members provide the resident ...
After reading the literature as well as seeing the interventions first hand, it made more sense to me. I am able to understand the reasoning behind the interventions a lot more, as a result of my research. The most important thing I learned is that each baby is individual. Each baby will respond to treatment differently and each baby will be affected differently by prematurity. I learned as a future nurse to treat individual patient as just that. Each patient deserves and individual plan of care, so that the best care possible can be provided.
Alabsi, S. (2010, August 11).
A Primer on Preemies . KidsHealth – the Web’s most visited site about children’s health. Retrieved May 10, 2011, from http://kidshealth.org/parent/growth/growing/preemies.html#a_Common_Health_Problems_of_Preemies
Gregory, D. S. (2006).
Maternity and women’s health . Clifton Park, NY: Delmar Learning.
Lowdermilk, D. L., & Perry, S. E. (2006).
Maternity nursing (7th ed.).
St. Louis, Mo.: Mosby Elsevier.