Clinical Learning Packet – Newborn Assessment

Newborn Client Initials: JS_____ Gender: M/F Date/Time of Delivery: 02/08/2013 1956_
Type of Delivery: SVD C/S IFD Vac Gestational Age by Dates:_40wks (as stated by primary nurse I could not find in chart)________
Age at Time of Assessments (hours): _13_______ APGARS: __8____ @ 1 min. ___9___ @5 min.
Blood Type/Rh: Newborn (not taken per agency protocol)_______ Maternal _B+________
Blood Glucose: Reason___________________Frequency__________Last Results:______

Newborn Weight: @ birth 3.28kg__________ Current 3.26kg_________ % Weight loss:0.61%______ Length:_21in______ HC:_13.5in______ CC:_13in_____
Feeding: Breast: _x_____Formula (type): ________________ Feeding Frequency/Amount/Time:_On demand usually every two hours_
Vitamin K (date):_ 02/08/2013 ____________ Erythromycin eye ointment (date): 02/08/2013 ______________ Hepatitis B (date):_02/09/2013_____________________
Circumcision (date):_02/09/2013__________ Metabolic Screen Due:________ completed_________Hearing Screening: Pass /Fail /Reassess
Comments:
_Clients Bilirubin score was 3.2 at 3hrs after birth. The physician asked for it to be watched. We assessed the bilirubin score again at 14hrs after birth and received a 5.2. The bilirubin will be assessed again at 18 hours after birth and the physician will decide on a course of action at that time per agency protocol. The baby is in the High intermediate group right now although he does not look visibly jaundiced. The baby as had one brick dust diaper and remained dry for the hour and half he was in the nursery.
Maternal/Family Data:
Mother’s Age: 22____ TPAL: 1001__________Rubella Status:____ HbsAg:____
GBS+ GBS- Treatment/# of doses_____________
Health Concerns: __OB complications AC <5% and, amniotic fluid was light meconium. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Family Structure: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Cultural/Ethnic Background:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Special Needs/Concerns:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ASSESSMENTS | ASSESSMENT FINDINGS (DESCRIBE) | WNL orNot WNL* | Nursing Interventions and Client Responses | Vital Signs: Crib/Warmer♥/Isolette♥ ♥Control Temp ♥Skin TempTemperatureHeart RateRespiratory Rate/SoundsBehavioral State:__________ | Client was in a potable crib.Skin was warm and dryT: 36.8°CHR: 140RR: 76 clearAlert | WNL | | Blood Glucose | N\A | | | Heel Stick Sites: ______________________Location/Appearance | | | | Umbilical Cord Moist/Drying/Dry | Drying in good condition | WNL | Cleaned base of umbilical cord with soap and water. | Circumcision Appearance/Care | Circumcision just preformed penis was red with slight serosanguinous fluid discharge | WNL | Client passed all post-surgery checks with only one score of 2 | ID Bracelet √ & # | √ I forgot to write down the number as we were very busy | WNL | | Security Device √ & # | I did not observe a security device | N/A | | NEUROLOGICALActivity: □ Active and Alert □ Lethargic □ Irritable □ Asleep | Active and alert | N/A | | Tone: □ Symmetrical □ Hypertonic □ Hypotonic | Symmetrical | WNL | | Movement: □ Moves all extremities = □ Smooth movements □ Jittery □ Limited | Moves all extremities | WNL | | Cry: □ Appropriate for age □ Weak □ High pitched □ Sleeping – not assessed | Appropriate for age | WNL | | Sutures: □ Overriding-depending on age □ Molding □ Wide □ Approximated | Overriding 13 hours old at assessment | WNL | | Fontanels: □ Soft and flat □ Tense □ Bulging □ Sunken | Soft and flat | WNL | | RESPIRATORY:Effort: □ Unlabored □ Labored □ Deep □ Grunting □ Nasal Flaring | Unlabored | WNL | | Breath Sounds: □ Equal/clear bilaterally □ Adventitious □ Absent | Equal and clear bilaterally | WNL | | Retractions: □ Absent □ Present/location | Absent | WNL | | CARDIOVASCULAR:Rhythm: □ Regular □ Irregular | Regular | WNL | | Murmur: □ None detected □ Noted | None detected | WNL | | Capillary Refill: _____sec | < 3 sec.? Yes | WNL | | Pulses: brachial/femoral: □ Present, equal □ Absent □ Unable to palpate | Present and equal bilaterallyIf unable, extremities color: | WNL | | Edema: □ None □ Periorbital □ Generalized | Periorbital edema noted | WNL | | Color: □ Pink □ Pale □ Mottled □ Acrocyanosis □ Cyanotic/Dusky □ Ruddy □ Jaundiced | Pink | WNL | | GASTROINTESTINAL:Abdomen: □ Flat □ Rounded □ Distended | Flat | WNL | | Tension: □ Soft □ Firm □ Rigid | Soft | WNL | | Bowel Sounds: □ Active □ Absent | Active in all four quadrants | WNL | | Stools:# in 24 hrs_2_____________Color:__________________Consistency:_____________ | 2 stools in 13hours 1 was considered a “brick dust” diaper which can indicate dehydration and one smear meconium diaper | Not WNL | Physician would like the infant watched for signs of dehydration | Urination:# wet diapers/24 hrs_______ | Unsure these are not counted or weighed unless ordered per agency protocol | | The nurse needs to be aware of the babys wet diapers to be able to assess the infants hydration status | Nutrition: Breast or BottleFeeding Frequency:________Amount/Time@ Breast: | On demand, frequency approx. every two hours unable to assess time at breast observation and assessment of infant occurred in the nursery | WNL | | SKIN:Moisture: □ Normal □ Moist □ Diaphoretic □ Dry, peeling | Normal, dry and cracked in areas | WNL | | Turgor: □ Instant recoil □ Tented | Instant recoil | WNL | | Mucosa: □ Moist □ Pink □ Dry | Moist and pink | WNL | | Rash: □ Newborn □ Other (describe) | Newborn | WNL | | NPASS Pain Score | Infant received a 2 pain score on his last circumcision assessment | WNL | Comfort Measures: 32.80mg/1.0ml of acetaminophen per agency protocol |
Bilirubin Monitoring
TcB (Transcutaneous Bilirubin) Score:_5.2__________ Hours Since Birth @ Assessment: _14_
Risk according to Bili Nomogram: _high intermediate risk___

Risk Factors Specifically Specific Interventions related to these Risks to Prevent for this Newborn: Hyperbilirubinemia in this Newborn:

Amniotic fluid having light meconium Assess mothers breast feeding technique as well as how
Breast feeding well the baby is feeding .

Clinical Learning Packet (CLP): Medication Administration WorksheetInstructions * Complete this form for each medication you administer during clinical. * Submit weekly to your Clinical Instructor (see Clinical Assignment Guidelines for details). * You only have to complete this form for each medication once; But please be sure to make revisions if the indication or use of the drug varied for a different patient. For example: ASA indicated for arthritis vs. ASA indicated for the anti-platelet effect in cardiac patientsREVIEW the *6 RIGHTS of Medication Administration* & SPECIFY medication information for your client. | WHAT | HOW | WHY | ASSESSMENT | SIDE EFFECTS | EVALUATION | Name, Dose, Route, Frequency | Drug Classification | Mechanism of Action | Desired Outcome-Why are you giving this medication? | What needs to be assessed? Give actual data | Most common and serious | Was the drug effective? Give actual /real data | 1.Acetaminophen 32.80 mg/1ml PO one time dose unless otherwise orderedNormal Dose 10-15 mg/kg/dose for this infant it would be 32.6-48.9__ | Nonopioid analgesic | May block pain impulses peripherally that occur in response to inhibition of prostgladin synthesis; does not possess anti-inflammatory properties; antipyretic action results from inhibition of prostaglandins in the CNS 9hypothalmic heat-regulating center) | To decrease clients pain. The client scored a 2 on NPASS | Assess clients pain, assess the clients lab values for AST,ALT, BUN and creatinine, assessfor for hepatotoxicity (For this client you would want to watch for increasing signs of jaundice) | Seizures, hepatic insufficiency, cholestatic jaundice, fulminant hepatic necrosis, bleeding, uremia, aplastic anemia, hemolytic anemia, leukopenia, thrombocytopenia, purpura, pancytopenia, Stevens-Johnson syndrome | Client seemed to be more comfortable and sleeping 0 on NPASS score | 2.Erythromycin Ophthalmic Ointment USP, 0.5% (Sterile)Apply 1cm line of ointment to lower conjunctiva sacNormal Dose _1cm line of ointment | Macrolide, anti-infective | Binds to 50s ribosomal subunits of susceptible bacteria and suppresses protein synthesis | prophylaxis of ophthalmia neonatorum | Assess for signs and symptoms of infection assess for an allergic reaction to this medicationThe client does not appear to have any adverse reactions to the medication and has no current signs of infection | Seizures, dysrhythmias, QT prolongation, hepatotoxicity, pseudomembranous colitis, anaphylaxis | The client does not appear to have any adverse reactions to the medication and has no current signs of infection | 3.Phytonadione (vit K) IM injection 0.5mgNormal Dose _0.5-1 mg within 1 hour after birth_ | Vitamin K, fat soluble vitamin | Needed for adequate blood clotting (factors II, VII, IX, X) | Prophylaxis of hemorrhagic disease of the newborn | Assess for bleeding or bruising , assess nutritional status, and monitor protime | Brain damage, hemolytic anemia, hemoglobinuria, hyperbilirubinemia, bronchospasm, respiratory arrest | The client currently does not show any signs of bruising the bleeding during circumcision was normal, the clients bilirubin rate is currently 5.2 | 4.Hepatitis B vaccine , recombinantIM injection 10mcg in 0.5ml Normal Dose_0.5 ml_ | vaccine | Hepatitis B surface antigen (HBsAg) which stimulates active immunity | Prophylaxis against Hepatitis B | Assess clients skin, previous injection reactions | Soreness where the shot was given Temperature of 99.9°F, Pruritus | The client did not appear to have any pain from the injection NPASS score 0, no irritation or signs of infection at injection site. | 5.Normal Dose___________ | | | | | | | 6.Normal Dose__________ | | | | | | |
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Clinical Learning Packet (CLP): Diagnostic/Laboratory Summary SheetInstructions * Review and record the below information for any diagnostic tests your patient underwent today. * Please include previous and/or future tests if it is relevant to primary medical diagnosis (For example, Dx pneumonia. Please include a description of chest x-ray, even if it were performed 2 days ago…). * Submit weekly to your Clinical Instructor (see Clinical Assignment Overview for details). | General Diagnostic/Laboratory Testing Information | Definition of Test | Describe the Procedure | Clinical Implications – Why is it often ordered by physicians? | Nursing Responsibilities | Desired Outcome or Normal Result | Resource & Page # | Transcutaneous Bilirubin Test | Take the small device and press it against the skin of the infants sternum 3 x in quick succession. | To assess for hyperbilirubin levels in infants that indicate jaudice | Preform the test at predetermined intervals per agency protocol record the findings and report any abnormal levels to the physician | 1-12mg/dl | Laboratory and Diagnostic Tests with Nursing implications pg 77-78 | Patient Specific Testing Information | Client’s Initials | Why did the client have the test? | Client Results | JS | Clients Bilirubin at 3hours was 3.2mg/dl physician wants the level to be watched | At 14 hours the test revealed a 5.2mg/dl this will be rechecked at 18 hours of age when the physician will enact a plan of care if needed per agency protocol |

Weekly Clinical Assignment: Nursing Care PlanInstructions * Enter subjective and objective data based on your history, physical and chart review * Identify one NANDA Nursing Diagnosis and the associated Long Term Goal; Clinical Faculty to determine if you are to care plan the Nursing Diagnosis of greatest priority, or if you may care plan according to other criteria * Identify a minimum of one outcome and three interventions per outcome; include rationale with citation for each intervention * For evaluation, determine if your plan of care met the desired outcome, and provide supporting data | Subjective DataSkin and sclera did not appear jaundiced on assessment. | Objective DataClient received 5.2mg/dl level at 14 hours of life, which places him in the high intermediate range on the bilirubin nomogram scale. | Nursing DiagnosisNeonatal jaundice related to high amount of circulating bilirubin as evidenced by bilirubin level of 5.2 mg/dl | Long Term GoalClient will have a normal bilirubin test in 48 hours | Desired Client Outcome(s)Receive bilirubin assessment and screening within the first week of life to detect increasing levels of serum bilirubinReceive nursing assessments to determine risk for severity of jaundiceDesired Client Outcome(s)Evacuate stool within 48hour of birth, and pass 3-4 stools per 24 hours by day 4 of life | Nursing Orders (interventions)Monitor transcutaneous bilirubin level per unit protocol or every 8 hoursPerform hour specific total serum bilirubin risk prior to newborn’s birth center discharge and document results of same | Scientific Rationale(For each intervention, include citation)Noninvasive bilirubin monitoring is a safe and effective means for monitoring bilirubin levels and determining risk for increasing serum bilirubin levels (American Academy of Pediatrics,2004)The use of an hour specific nomogram for designation of risk in healthy, late preterm, and term infants, as well as clinical risk factors, may be used to determine the relative risk of rapidly increasing bilirubin levels requiring medical intervention such as phototherapy(American Academy of Pediatrics,2004; Bhutani et al, 2006) | Evaluation(If you did not execute the intervention, state how you would evaluate the desired outcome) Clients bilirubin level at 14hours of age was 5.2mg/dlEvaluated infants risk on nomogram for the appropriate hour of age and received the result of high intermediate risk for this infant. The physician will decide on a plan of care after the assessment done at 18hours of age per agency protocolEvaluation(If you did not execute the intervention, state how you would evaluate the desired outcome) Infants first stool was a “brick dust” diaper and client has only stooled once more a smear of meconium at 14 hours of age | | Nursing Orders (interventions)Assess neonates stooling pattern in the first 48 hours of life | Scientific Rationale(For each intervention, include citation)Delayed stooling may indicate inadequate breast milk intake and may further increase reabsorbtion of bilirubin from neonate’s intestine ( Blackburn, 2007) | |

Clinical Learning Packet: JOURNAL REFLECTION CLINICAL SELF-EVALUATION
Directions: Chose at least 1 discussion point from each of the headings. Discuss each, using specific examples from your clinical experience. Submit weekly to your Clinical Instructor (see Clinical Manual for details).

Assessment - Discuss Points * How do you think your overall clinical day progressed? I think it progressed well. I was able to assess multiple infants this allowed me to hone my technique and become better at assessing the infant heart rate and respiratory rate. I was also able to perform 2 IM injections and take an infant’s blood glucose. I was able to also watch a circumcision from start to finish and preform the clients surgical checks after surgery. In was shown how to assess and score a infant going through withdrawel as well how to perform an NPASS score. * Was there any part of your clinical experience you would do differently the next time? The same? * Did anything about your patient’s assessment surprise you? Why?
Planning - Discussion Points * List the steps you took to prepare yourself for your clinical experience. Discuss what worked and what didn’t. I reviewed a normal infants heart rate and respiratory rate and how to properly assess them. It took quite a few assessments to get the hang of doing an infant’s HR and RR since they are so much faster than an adult. I was by the end of the day able to get close to the primary nurses assessment. * Give an example of a nursing-related plan that did not unfold as you expected; Describe how that impacted your day; the patient’s day.
Implementation - Discussion Points * Did you meet any challenges or barriers implementing the plan of care for your patient? * If so, how did you (or could you have) overcome them in the clinical setting? * Were there any skills you performed well? Any that may need improvement? Describe. I was able to give two IM injections to infants. I think I performed them fairly well I do need to become more comfortable in drawing up my medication and getting all of the bubbles out of the syringe. * Do you feel you made a connection with your patient and/or family member/s? * Did you meet any challenges to completing or performing your assigned patient care (tasks)?
Evaluation - Discussion Points * Identify an action plan to help you to work on skills you think need improvement. I can utilize the injection practice needles and medications given to us in fundamentals to practice drawing up medications and removing the bubbles. I can also utilize the nursing lab if I need further help with my technique. * Identify 1 GOAL for next clinical and list why this goal is important
Professional Development - Discussion Points * Name the most important lesson or message you took home today That assessment of an infant’s bilirubin levels by a transcutaneous method or blood test is crucial. Because in some incidences such as with my infant they do not display visual cues that their bilirubin levels are elevated. * Discuss how you will use what you learned today in your practice * Describe a nursing role you observed and how you think it has made an impact on your practice or a patient’s outcome/life
References:
Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook an evidenced-based guide to planning care (9th ed.). St. Louis, Mi: Mosby Elsevier. (Pg 513-515)

LeFever Kee, J. (2010). Laboratory and Diagnostic Tests with Nursing Implications (8th ed.). Upper Saddle River, NJ: Pearson. (pg77-78)

Mosby's Drug Guide for Nurses (9th ed.) (L. Skidmore-Roth, Comp.). (2011). Wiley-Blackwell. (pg 39-40, 805-806, 1141)

http://reference.medscape.com/drug/engerix-b-recombivax-h-b-hepatitis-b-vaccine-343151#10

http://www.drugs.com/pro/erythromycin-ophthalmic-ointment.html