Question

Case Scenario

Baby Girl CBX is delivered at 10:35 pm, 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

POINTS TO STUDY:

1. Develop a nursing process based on the case.

2. Identify all health problems and make justifications.

3. Make a nursing care plans to all identified problems.

4. Make a health teaching plan as it applies.

5. Explain the physiology / pathophysiology of the client’s problem.

6. Make a drug study.

7. Explain the importance of the laboratory tests.

8. Explain all newborn reflexes.

9. Do an EBN for top priority problem.

Answer 1

Ans1. The nursing process includes 5 steps--

I] Assessment---

A. Aiway= Check airway, look for chest movement, auscultate the chest and list for air entry and feel the chest rising and falling.

B. Breathing= Look at skin color, check if there is any noise during breathing, look for any tubings.

C. Circulation = Check for blood pressure, it will be increased as the case is of C- section, consider blood gas ratio, temperature check is done, heart rate should be checked timely. Look for clotting, it will be increased as it's a c- section case.

D. Check for the IV line, and the swelling in the body, skin texture, do they need a urinary catheter, a stool softener is needed or not.

E. Check her GCS status.

Fundus = Fundus is top of the uterus, and it should be checked after birth fundus should be firm, midline and it should be at the level of umbilicus that is belly button. 12 hours after the fundus should be 1cm above the uterus and then after it should descend 1 to 2 cm every hour. It is advised to patient to void every 3 hours to decrease any future risk. Patient is asked to do breastfeeding in order to release naturally occurring oxytocin which will help uterus contract and will prevent bledding.

Check for lochia, which is a discharge comes after delivery

They are 3 stages of lochia --

1. Lochia Rubra -- It's a bright red discharge, which is expected to come till 1 to 2 days after delivery.

2. Lochia Serosa-- Pinkish - brown color discharge which will last for about 4 to 10 days after delivery.

3. Locha Alba -- White- yellow in color and it will last for 11 days to 8 weeks after delivery.

Breastfeeding-- The Patient should be informed about how important is breastfeeding both for her and for her baby. And educating the mother on the importance of colostrum for her baby and oxytocin release related mechanism to breastfeeding.

Should teach her the correct way to breastfeeding, that not only the nipple but some part of the areola should also be in the mouth of the baby while breastfeeding.

II] Nursing diagnosis --

Following points are diagnosed--

a. Mother is at high risk of developing infections and sepsis as it's her 5th pregnancy and she has no healthy eating habits which can risk the baby as well and also because of c- section there is a risk of infection of the lining of the uterus.

b. Baby is at risk of developing slow growth, because of her smoking and drinking habits.

c. Increase risk of pelvic organ prolapse because of multiple pregnancies.

d. As tetanus injection is given once out of 5 pregnancy baby is at high risk of diseases like whooping cough and also it acts on respiratory muscles.

e. Because of the C- section, blood loss is high and if not taken proper measures it could be fatal.

III] Planning

Extra care, educating the mother about the benefits of breast feeding and family planning, how having pregnancy again and again without family planning is fatal to her and to her baby.

Give stool softener, NSAIDs in case of increased pain, IV glucose if can't eat properly, blood transfusion in case of severe bleeding, Foley's catheter in case if there is difficulty standing for the first few days.

IV] Implementing ---

Implement the plans.

V] Evaluating ---

Evaluate if the bleeding is in control, vitals are stable, the patient is not dehydrated, and is in less pain.

Ans 2. Health problems associated --

1.High blood pressure = As the patient has undergone surgery and age is also high, and there is increased bleeding, the chance of high blood pressure is significant.

2. Slow growth of the baby, as the baby didn't receive healthy supplements in the gestation period as the mother's eating habits are poor, and also didn't receive enough medical check-ups. The baby may have slow growth, stunted growth, less development of the brain, and malnourished.

3. As the mother is not much aware of immunization benefits, it can lead to further chances of the baby getting more prone to infectious disease.

4. Increased chances of the mother having pelvic organ prolapse because mother till now have had 4 deliveries which can further add on to her pelvic muscles get weakened.

5. Increased chance of developing an infection of the lining of the uterus (endometritis).

6. No consistency of tetanus, can lead to a further problem on the baby's health.

7.Anaemia as blood loss is much in c- section, also the eating habits are not healthy and supplementation and medication prior to pregnancy are irregular.

8. Back pain