NICU Patient

NICU Patient

1. Positive for trisomy

   • Decreased muscle tone, especially in head
     • Risk for injury r/t trisomy
       • Goal: patient remains free of injury and parents identify factors that increase risk for injury
         • Intervention 1: Identify the patient's risks and limitations (Ackley 10th edition, p.487). Rationale: will identify what dangers the patient is at risk for in order to prevent them before they happen
           • Intervention 2: Remove all possible hazards in the environment (Ackley 10th edition, p.488). Rational: limits the opportunities for injury
             • Intervention 3: Place injury prone patients near the nurses station (Ackley 10th edition, p.488). Rationale: more frequent status assessments and rapid responses if necessary
               • Intervention 4: Teach parents how to identify client safety issues and how to intervene (Ackley 10th edition, p.487). Rationale: will allow primary caregivers to keep client safe where the risks are higher
                 • Intervention 5: Take extra precautions to accommodate for patient safety based on client limitations. Rationale: personalizes precautions to take into account what the client can and cannot do safely
                   • Evaluation: goal met, as no injuries occur, and parents are aware of the newborn's limitations. However, the risk remains, and will follow the pt for the length of her life

2. Had previous episode of hyperbilirubinemia, pulmonary HTN w/ low O2 saturation

   • Dx Cholestasis; US showed "adherent biliary sludge"
   • Appendectomy was performed along with duct repair

3. VS: 90/53, HR 169, RR 36, 37.2 C

4. NKDA

5. 3 week old F patient born via C/S

6. Positive for MTHFR gene mutation

7. 3.518 Kg

8. Jaundiced

9. Poor bleeder, evident by multiple venous and arterial punctures and heel sticks for blood samples

   • Risk for ineffective tissue perfusion r/t high blood viscosity and infant microvascularity AEB Htc , MCH , triglycerides, and improper bleeding
     • Goal: maintain perfusion above 95% and no evidence of hypoperfusion such as paleness, decreased cap refill, increased HR or RR during the length of the shift
       • Intervention 1: Assess pulses at all extremities and note any absences and report them to physician (Ackley 10th edition, p.811). Rationale: will identify any vascular obstructions in the body's areas of lowest priority
         • Intervention 2: Note skin color and temperature and report any blue, purple, or black spots (Ackley 10th edition, p.811). Rationale: will identify areas presently affected my hypoperfusion
           • Intervention 3: Observe for signs of DVT and other clots (Ackley 10th edition, p.813). Rationale: will identify complications before they cause more significant issues
             • Intervention 4: Monitor patient's Hct, and triglyceride levels. Rationale: will reveal improvement or worsening of patient's condition.
               • Intervention 5: assess capillary refill (Ackley 10th edition, p.811). Rationale: will identify circulation & perfusion status directly on that tissue
                 • Evaluation: goal met as patient had no incidence of hypoperfusion. However, the risk remains

10. Heart murmur present

11. Triglycerides 327

12. Htc 59.9%, MCH 36.2

13. TSH 6.229, T4 2.13