Question

QUESTION: MAKE 4 NURSING DIAGNOSIS

Case Scenario

Baby Girl CBX is delivered at 10:35pm, September 14,2020 via caesarian section 6 hours ago. Her admitting diagnosis is Full term, BB Girl wt.8lbs, Apgar Score 1st minute 8, Apgar score 5th minute is 10.

Her vital signs are as follows:

CR= 150bpm; head circumference= 33 cm; chest circumference =34 cm; Abdominal circumference= 28; Length= 52 cm

Good Cry but with acrocyanosis for the first minute.

Mother’s History: G5 P4 (5004), 1-time CS, 3x VBAC, LMP December 20,2019.

Menarche = 14 years old

Age= 40 years old

Received tetanus toxoid once only for the five pregnancies.

Prenatal checkup, twice at Health Center XXX

No family planning

Cannot recall childhood immunizations

Educational attainment: elementary graduate

Drinks liquor and smokes cigarettes prior to pregnancy.

Preferred foods: Fried Chicken and occasional junk foods with a bottle of coke

Mother has wrong perception about immunizations and did not practice breastfeeding with previous children.

Chief complaints upon admission: Mother is in severe abdominal pain, Cervical dilatation is 10cm and fully effaced. BOW already ruptured 2 hours prior admission.

Checking the client’s record, the following are written in the Doctor’s Order Sheet:

September 14, 2020 11pm

• Please admit to post-partum ward

• Do New Born Care • CBC, typing

• Apply Ophthalmic ointment OU

• Do Apgar Scoring • Give Vit K 1mg IM

• May administer BCG .05 cc Intradermal once

• Give hepatitis B Vaccine .5 cc IM

• Start Gentamicin 40mg IM once a day for 7 days

• Ampicillin 125mg IM twice a day for 7 days

• For breastfeeding

• For newborn screening

• Do HGT now

• Assess newborn reflexes

• Monitor vital signs every shift

QUESTION: MAKE 4 NURSING DIAGNOSIS

Answer 1

Nursing diagnosis for new born

1. Ineffective peripheral tissue perfusion related to impaired oxygen transportation as evidenced by acrocyanosis of the extrimities.

2. Risk for infection related to altered immune system and early BOW rupture as evidenced by early intiation of antibiotic regimen

3. Risk for hypothermia related to sudden change in the environment from intra uterine to extra uterine as evidenced by cool extrimities.

4. Interrupted breast feeding related to insufficient parental knowledge regarding breast feeding as evidenced by maternal anxiety and verbalization

Nursing diagnosis for mother

1. Acute pain related to Intensified uterine contractions as evidenced by fully dilated cervix and verbalization

2. Ineffective breast feeding related to insufficient parental knowledge regarding importance of breast feeding as evidenced by verbal description.

3. Knowledge deficit related to health and safety practices like immunization as evidenced by verbalization.

4. Imbalanced nutrition more than body requiremnet related to excess intake of fast foods.

5. Risk for complication like lifestyle disorders related to unhealthy eating practices and smoking