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Student: Samantha Miller

Date(s) of care: 09/25/2015


Patient Information
Pertinent Medical History: Baby B was born 09/23/2015 @ 6:43. Delievery CS for HIV+ mom. Initial Assessment: weight was 6 lb, 11
oz. length- 18 HC- 13.25T-97.8F, resp-38; HR-134. Baby active; color is pink with olive undertones, good cry, head
normocephalic,fontanelles and sutures WNL.Milia present across nose. Hair is soft, black and sparse. Eyebrows and lashes
present, eyes and ears level, nostrils equal, no flaring observed. Sucking pads present. Palate intact, good suck reflex. Eyes
bright dark brown, + blink reflex, baby is responsive to sound and movement. No drooping or paralysis noted in face. Sclera
bluish-white. Ears are symmetrical, well-formed. No lesions noted. Clavicles straight and intact. BL lung expansion, Lungs clear
BL, nipples symmetric, flat. HR regular, no murmurs or thrills noted. Abdomen protruding, umbilical cord dry, no bleeding. Active
bowel sounds x 4 quad. No inguinal bulges, femoral pulses +1/4. Genitals symmetrical; pubis dark brown and engorged, scant
smegma present within labia. Buttocks symmetric, anus patent, no dimpling at coccyx. Symmetric buttock creases. All reflexes
charted as present. Apgar 8/9.
Occupation: newborn baby
Family History: FOC not present, great-grandmother has band.
Educational Level: none
Religion: none; mother is Baptist
Medications: Zidovudine (Retrovir)
Sociocultural considerations: family is of low socioeconomic status; may need referrals to outside agencies
ALLERGIES: NKA
Current lab findings: blood Type O+
DNR status: full CPR
Current diagnostic findings: risk for HIV Aids r/t maternal infection of HIV
G 2, T1, P 1, A 0, L 1

Current Medication
Name
(generic & brand name)

Classification

Dosage

Action

Zidovudine (Retrovir)

Nucleoside Reverse
Transcriptase Inhibitors

PO 12mg/1.2mL syrup
Q12 hours at 10 oclock

Retrovir prevents HIV


from altering the genetic
material of healthy Tcells. This prevents the
cells from producing
new virus and decreases
the amount of virus in
the body.

Side Effects and


Contraindications
Sleep problems
(insomnia)
Mild nausea,
constipation
Joint pain
Headache; or
changes in the shape
or location of body fat
(especially in your arms,
legs, face, neck, breasts,
and trunk).

Nursing Implications

It is not known whether


Retrovir passes into breast
milk and what effects it may
have on a nursing baby.
However, to prevent HIV
transmission of the virus to
uninfected babies, it is
recommended that HIVpositive mothers not breastfeed.
Be sure that you understand
the correct dose to give the
child. As a child grows, the
dose of Retrovir will need to
be increased on a regular basis.

Assessment
(Supporting data)

Nursing Diagnosis
(NANDA diagnostic statement)

Goals & Expected Outcomes


(Realistic, timed, measurable)

Nursing Interventions
(Strategies or actions for care)

Rationale for interventions


(Include source and page numbers)

Evaluation
(Clients response to nursing actions
& progress toward achieving
goals & outcomes)

Subjective: Baby is calm,


soothes easily, does not appear
uncomfortable

Risk for imbalanced


body temperature r/t
extreme of age (newborn
status)

1.

Infant will
maintain its body
temperature
between 97.0
and 99.0F for
entire shift

1.

o
Objective: Baby Bs axilla
temp: 97.8 F; skin warm and
dry

2.

Verbalize
understanding of
individual risk
factors and
appropriate
interventions.

2.

3.
1

Demonstrate
behaviors for

Assess infants
temp each hour.
If temp is above
101F, take
measures to bring
temp to normal
range:
Administer
antipyretics as
ordered
Monitor and
document related
symptoms with
specific regard to
febrile seizures
Monitor/maintain
comfortable
ambient
environment.
Provide
heating/cooling
measures as
indicated.
If temp is < 97.0F,
take measures to
bring temp to
normal range:
place infant under
warmer

Infants lack mature


thermoregulation. Temps too high
or too low can disrupt acid-base
balance, causing seizures or
shock.
Infants are at risk for febrile
seizures r/t immature
thermoregulation and must be
safeguarded against further
sequelae.
Signs of neonatal seizures
include:
Repetitive sucking
Repeated extending of the
tongue
Continuous chewing
Continuous drooling
Long pauses in breathing
(apnea)
Rapid eye movements
Blinking/fluttering of eyelids
Fixation of gaze to one side
Body aligned to one side
Pedaling/stepping
movements of legs
Paddling/rowing movements
of arms

Rapid muscle jerks 1

or on mothers
chest under blanket

Young infants cannot initiate


compensatory regulation of
temperature and can become
septic at body temps below 97.0F

3.

Review potential

Infants can become dehydrated

Goal Met: Baby Bs temp. remains


WNL for entire shift

monitoring and
maintaining
appropriate body
temperature.

4.

5.

Mother will be
able to return
demonstrate
understanding of
kangaroo care
and other
methods of
warming baby, as
well as
demonstrate her
ability to assess
babys axillary
temperature by
discharge.
Infant will
maintain
respiratory rate
and normal
thermoregulation
patterns.

problem/individual
risk factors with
client/ SO(s).
Instruct in
measures to protect
from identified risk
factors.
4.

Nurse will teach


mother proper
technique for
kangaroo care.

5.

Nurse will monitor


for signs of
respiratory distress
and other
symptoms of
thermoregulation
(lethargy etc.) q 30
mins.

under warmer if not carefully


monitored.
Reference: Coxs Clinical
Applications of Nursing
Diagnosis; pg.141
http://www.epilepsyfoundation.or
g/infants/neonatalonset.html

Assessment
(Supporting data)

Subjective:
MOC states I do not want to
breastfeed my baby because I
do not want to risk her getting
infected

Nursing Diagnosis
(NANDA diagnostic statement)

Risk for HIV infection


r/t maternal infection of
HIV aids

Goals & Expected Outcomes


(Realistic, timed, measurable)

1.

Minimizing the
risk of vertical
transmission of
HIV

1.

2.

Recognizing
neonatal HIV
infection early

2.

Virologic tests
allow early
diagnosis of HIV
infection

3.

Preventing
opportunistic
infections

3.

Closely monitor
infant until age 18
months to
completely rule out
HIV infection

Objective:
Baby L is consuming 20-30 mL
of formula per feeding; Babys
weight has remained constant
since birth (6 lb, 11 oz)

Nursing Interventions
(Strategies or actions for care)

4.

Addressing
psychosocial
issues

4.

Six weeks of
neonatal
zidovudine therapy

Laboratory
monitoring,
screening for
perinatal
infections,

Rationale for interventions


(Include source and page numbers)

Evaluation
(Clients response to nursing actions
& progress toward achieving goals
& outcomes)

Prophylaxis for
Pneumocystis carinii
pneumonia should be
initiated when HIV-exposed
infants are six weeks old
and should be continued for
at least four months,
regardless of negative
virologic tests, because P.
carinii pneumonia is often
the initial presentation of
HIV infection in infants.

Goal met: There has been no infection of


HIV in Baby B as of yet.

Reference:
http://www.aafp.org/afp/200
2/0515/p2049.html

Goal met: The parents can verbalize the


reasons for their babys medications and t

5.

Parent teaching

5.

appropriate social
support, and other
modifications of
standard infant care
Let the parents
know everything
the baby is going
through to prevent
HIV and why.