Please use the assigned patient case study for your clinical judgement plan ,some info may not be included in the case study such as culture, religion, SDOH, and some assessment data. If this is the case please do not leave the box in the CJP blank. Discuss how you would gather the info or what you would expect with this type/age of patient. The nursing process attached is a previous assignment done as homework which could help for the clinical judgent since its same patient and infection. Some commonly missed areas in the clinical judgement plan:
Not providing rationales/sources for patho
Not including pathophysiology of past medical/surgical history
Not properly completing calculations for min/max dosage per weight of patient
Infection in the Newborn
Revised 4-25-21
Data Collection:
Chief complaint/History of Present Illness: Rennie is a 28-day-old female presenting to ER during the night with presenting complaint of apneic episodes approximately 2 times/day with changing color to
blue. Apneic episodes lasts 1-2 minutes, resolves with gentle to moderate stimulation. Apneic episodes not associated with vomiting/spit ups. Baby completely recovers to her baseline with stimulation. Baby always sleeps on her back, no family history of SIDS. The current episode started
more than 1 week ago. The problem occurs intermittently. The problem has not changed since onset.
Nothing aggravates the symptoms. Pertinent negatives include no fever, no stridor, and no intake of a foreign body. She had a lumbar puncture and chest X-ray as well as arterial blood gases and lytes done in ER. Urinalysis and culture have been done. Ceftriaxone 369mg IV was given in ER after
culture obtained.
Personal/Social History: Family lives/stays sometimes in a friend’s place (who does not let the baby’s dad in) and a homeless shelter (the dad stays in a shelter and is allowed to bring family in).
Mother says she is a medical assistant, currently unemployed. Both parents smoke, they state they do not smoke around the baby.
PMH: Born 39 weeks, C/S (FTP) 8 lbs 8 oz (3.85kg), no birth/nursery complications. Medical history:
significant for GERD, hiccups, and weight loss thought to be due to lactose intolerance, she has since been placed on soy formula with rice cereal added to the formula. Has been in ED x4 for umbilical
bleeding (resolved), GERD (improved on Pepcid), thrush (put on Nystatin) and conjunctivitis
(resolved).
Current Medications:
Ampicillin 185mg IV every 6 hours
Ceftriaxone 369mg IV q 24 hours
Nystatin 100,000 unit/mL suspension po every 24 hours
Nystatin (MYCOSTATIN) cream topical 3 times a day
Famotidine 1.85mg PO daily
Patient Care Begins: When you walk into the room for your initial assessment, you are
overwhelmed with the smell of dirty feet, which appears to be from dad since he is barefoot and his Timberline boots are under the crib. The baby is whimpering and neither parent seems to notice.
You ask when the baby last fed and Dad tells you he doesn’t know but probably not since the middle of the night as he just woke up. You pick up the baby and notice a cold soggy wet diaper that you immediately change. You tell the parents that a renal sonogram is scheduled for the morning, as well
as several consults.
Throughout the morning, you observe the mother sleeping most of the time and dad is engrossed with his laptop. Two grandmothers are in the room talking most of the day. Neither parents nor
grandmothers seem to pick up on the baby’s cues for feeding or wet diapers and the baby does not cry very much. Other patients are complaining about the smell in the hallway by your baby’s room.
Your Initial VS, 0730:
T: 36.6 *C (97.8 *F)
P: 164 BPM
R: 64 RR
BP: 80/42 mmHg
O2 sat: 95% on RA
Pain: 1/10 FLACC
Weight: 3.69kg (8lbs 1.6oz)
Your Initial Nursing Assessment:
Gen: Asleep, comfortable, reactive to stimulation. Resp: no congestion or nasal discharge, MMM.
Slight increased WOB manifested by +nasal flaring; no retractions, lungs clear bilaterally A/P&Lat.
CV: RRR, brachial and femoral pulses 2+ equal bilat, cap refill 94%
Similac Advance ad lib
IVF: D5W1/2NS + 20mEq KCL @ 15 ml/hr
May DC IV when taking PO fluids
Strict I & O every hour
Activity ad lib
Droplet Precautions
Reflux Precautions
1. Dosage Calculation:
Medication
Safe dosage range calculations:
Ampicillin 185 mg IV
every 6 hours
CefTRIAXone 369 mg
IV q 24 hours
Started in ER
Nystatin 100,000
unit/mL suspension
po every 24 hours
Nystatin
(MYCOSTATIN)
cream topical 3
times a day
Famotidine 1.85mg po
daily
IVF D5W +
0.45%NaCl @ 15 ml/hr
Maintenance fluid calculation:
Lab Results:
CBC
WBC (4.5-11.0)
HGB (12-16)
PLTS (140-440)
Neuts. % (42-72)
Bands % (0 – 5)
Lymphs % (46-76)
Mono% (1-10)
Eosinophiles % (0-5)
Current
12.1
13.8
574
74
14
20
8
0
Basic Metabolic Panel
Sodium (134-146)
Potassium (3.0-6.3)
Chloride (98-106)
Glucose (74-127)
BUN (7-25)
Creatinine (0.5-1.3)
Current
143
4.8
106
78
8
0.2
UA
Color (yellow)
Clarity (clear)
Sp. Grav (1.002-1.030)
Current
Light yellow
Cloudy
1.006
Mechanism of action and Nursing
implications:
Protein (neg)
Glucose (neg)
Ketones (neg)
Blood (neg)
Nitrate (neg)
RBC’s (0-2)
WBC’s (0-5)
Bacteria (0-few)
Epithelial (0-few)
Neg
Neg
Trace
Trace
Neg
1
4
Few
Few
Spinal Fluid
Appearance CSF (clear)
Polys CSF (0-30)
Lymphs CSF (0-100):
Monos CSF (0-100):
Eosinophiles CSF (0-1):
Glucose CSF (50-80):
Protein CSF (10-45)
Arterial Blood Gases
pH (7.38-7.42)
PaO2 (75-100)
PaCO2 (38-42)
HCO3 (22-28)
O2 sats (94-100%)
Oxygen delivery
Current
Bloody
15
75
8
1
48
109
Current
7.38
99
45
27
98%
.21%
Initial
7.37
100%
48
24
100%
0.5L
Radiology Reports:
Chest X-Ray IMPRESSION: Mild strandy and hazy pulmonary opacities diffusely within both lungs.
This patient remains within the upper age range of the neonatal period and neonatal pneumonia
remains within the differential diagnosis. Bronchiolitis related to a viral infection is in additional possibility.
Complete Abdominal Ultrusound: The liver is homogeneous in echogenicity. No focal hepatic mass or intrahepatic ductal dilatation is identified. The gallbladder is not abnormally distended. There are no gallstones, wall thickening or pericholecystic fluid. The common duct measures less than 1 mm. No significant sonographic abnormality of the pancreatic head, neck or body is identified. The spleen is homogeneous in echogenicity, measuring 4.2 cm in length. The right kidney is normal in echogenicity relative to liver. The right kidney measures 4.7 cm in length. Corticomedullary
differentiation is preserved. There is no right-sided renal mass, calculus or hydronephrosis. The left kidney measures 4.5 cm in length. Corticomedullary differentiation is preserved. There is no left-sided renal mass, calculus or hydronephrosis. The bladder is partially distended with urine and demonstrates a small amount of debris.
Doppler evaluation demonstrates normal monophasic hepatopetal flow within the main portal vein.
The visualized portions of the aorta and IVC demonstrate normal gray scale and color Doppler appearance.
Normal renal lengths for age range from 4.0 to 6.0 cm.
IMPRESSION:
1. Small debris in bladder.
2. Otherwise, normal abdominal ultrasound.
II. Evaluation:
Evaluate the response of your patient to nursing & medical interventions during your shift. All physician orders have been implemented that are listed under medical management
VS, 1600:
T: 36.7
P: 134
R: 48
BP: 96/54
O2 sats: 98% on RA
Pain: 1/10 FLACC
I&O
I
IV:
Enteral:
180
265
O
Urine/stool:
Emesis:
277
60
Nursing Assessment:
Gen: Asleep, comfortable, reactive to stimulation. Resp: no congestion or nasal discharge, MMM.
No increased WOB, no nasal flaring or retractions, lungs clear bilaterally A&P, no wheezing. CV:
RRR, brachial and femoral pulses 2+ equal bilat, cap refill