Easter College

DEPARTMENT OF NURSING
Easter School Road, Guisad, Baguio City
Phone: (074) 424-5483
E-mail: ndcon2011@gmail.com
Website: www.eastercollege.ph

MODULE 1
Case Study for
NCM 107: CARE OF MOTHER, CHILD & ADOSLESCENT (well client)
NURSERY CLINICAL ROTATION
(Neonate)
2C

INSTRUCTIONS:
CONGRATULATIONS for pursuing with your dream of becoming a nurse.
Read the case of a patient whom you are to provide nursing care. Take time to analyze and process the
information provided, before answering the activities following each section of your module.
You may take a break, as necessary. You can ask your friends, classmates, parents, or any person whom you
think can help you understand but remember a greater amount of output should come from you, as you are the
LEARNER here.
Of course, you can ask me, your clinical instructor, for clarification on areas you do not seem to understand and
do not know what to do. Would be thankful and gladly help you on your learning needs. You can contact me
through my number: ________________________.
For you to conduct all the requirements for this rotation, we shall follow the schedule below:
Online:
Day 1: AM: read on your patient’s case and answer the given activity.
Day 2: AM:
Day 3: AM: rotational exam (20 points), feed backing.
Modular: Remember that you are given 2-3 days to finish this task.

GENERAL HISTORY:

This is a case of Patient B, Male, 1 day old neonate admitted at BGH-MC

Admitting Diagnosis:
Live singleton male term 38-39 weeks AOG by Ballards Score inborn via NSD with a bithweight of 2.87 kgs, AGA

Principal Diagnosis:
Live singleton male term 38-39 weeks age of gestation by ballards score, inborn via normal spontaneous delivery with a
bithweight of 2.87 kgs kgs, Appropriate for gestational age

Prinicpal Procedure: BCG vaccination

Hepa B vaccination
Newborn Hearing Test
Newborn Screening

Date of Birth: September 28, 2020

Time of Birth: 8:00AM

Anthropometric Measurements:
Weight: 2.87 kgs
Length: 50 cm
Head Circumference (HC): 35 cm
Chest Circumference (CC): 32 cm
Abdominal Circumference (AC): 31 cm
Prepared by: Brando B. Badecao
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Page 1 of 7
Mid Upper Arm Circumference (MUAC): 12 cm
Vital Signs:
CR: 150 bpm
RR: 55 cpm
Temp: 36 degrees Celsius
O2 Saturation: 98 %

Apgar Score:

SIGN 0 1 2 1 minute 5 minutes

Color Blue or Pale Acrocyanotic Completely Pink 1 2

Heart Rate Absent <100 /minute >100/minurtes 2 2

Reflex No response Grimace Cry or Active 1 1

Withdrawal
Irritability

Muscle Tone Limp Some Flexion Active Motion 2 2

Respiration Absent Weak Cry; Hypoventilation Good Cry;Crying 2 2

Total 8 9

Ballards Scoring:
Total Neuromuscular Marturity Score: 18
Total Physical Maturity Score: 18

38-39 Weeks

Medications given were: Erythromycin ointment on both eyes

Vitamin K 1mg intramuscular at right thigh
0.5 ml Hepatitis B vaccine intramuscular at left thigh
0.05 ml BCG intradermal at right deltoid

Prepared by: Brando B. Badecao

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 ACTIVITY 1 &2: What are the pertinent positive and negative date or finding that you think are relevant in the formulation of your nursing
diagnoses
FEEDBACK: Congratulations you can now proceed with the activity.
Note: can also be given through text

PHYSICAL EXAMINATION
Fill in the information needed based from the data above
As for the Physical Examination (PE) using the head to toe assessment encircle the positive assessment of the neonate.
Check what is appropriate to the case. If there is/are no given choice identify a pertinent positive assessment.

Date and Time of Birth:_______________________________ (__x_) Inborn (___) Outborn

Anthropometric Measurements:
Wt:____________________L:_______________________
HC:__________________CC:_______________________AC:______________________MUAC:________________________

AS:__________________
BS:__________________

General Condition Flaccid or Active or Awake

Vital Signs:
CR
RR
Temp
O2 sat
Skin color Cyanotic or Acrocyanotic or Completely Pink
Head:
Scalp
Ears
Eyes
Nose
Mouth
Neck
Chest/ Lungs
Heart
Abdomen
Umbilical Cord/ Stump
Genitalia:
(___)Male Descended Testes or Undescended Testes
(___)Female
Anus Patent Anus or Imperforated Anus
Spine/ Back

Prepared by: Brando B. Badecao

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 Extremities:
Upper
Lower
Neurologic:
Cry
Muscle Tone
Reflex
Sucking

FEEDBACK: You might find it easier for you if you have your textbooks with you. Congratulations you can
now proceed with the activity.

DIAGNOSTIC STUDIES /PROCEDURES

Procedures/Laboratory Test Reference/normal values Purpose

1. Vital Signs
2. Anthropometric Measurements
3. Apgar Scoring

4. Ballard Scoring

5. Newborn Screening

6. Newborn Hearing Test

ACTIVITY 3: Using a reference book (can specify), you have to fill in the values that are asked and its purpose
● Option: can put the normal values on some or put rationale for some and they will identify the specific lab test

FEEDBACK: That the spirit, keep going. You might want to have a few minutes break before proceeding to the areas of the module.

ACTIVITY 4: Read about your patient’s diagnosis using your textbook (Maternal and Child).

Identify the following Terms Meaning

Live Singleton Male Term

GP

GTPALM

AOG

NSD

AGA

Reference: Textbooks /Online resources allowed but should not come from blogs, Wikipedia,

FEEDBACK: KEEP UP THE GOOD WORK, what you are doing will keep you focused and enable to understand your patient
the best way possible. It may be hard on you at the start but doing it often, you will soon find it easier. Remember, no pain no
gain.

PRESCRIBED THERAPEUTIC (MEDICAL/SURGICAL) MANAGEMENT, AND HEALTH PROMOTION PROGRAMS

- Provide appropriate medical / surgical interventions
- Limit to at least 5 drugs if necessary

Prepared by: Brando B. Badecao

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 Activity 5: After reading your textbook or notes on pharmacology and/or medsurg book, answer what are asked on the following table.
Drug/ Classification Dose/Route/Frequenc Mechanism of action Common Side Effects Nursing responsibilities
y
1.

2.

3.

4.

Reference/s: Textbooks /Online resources allowed but should not come from blogs, Wikipedia,

FEEDBACK: I hope you were not intoxicated by these drugs. Remember that these are important in saving your
patient’s life and it should be monitored for its therapeutic and side effects.

ACTIVITY 6: Applying the nursing process, integrate all the significant findings obtained in the analysis of the case and formulate a nursing
care plan for your patient. Use the given table/format presented.
Formulate 2 well diagnosis for the neonate
Make use of your NANDA book.

DATA GOALS/ Expected ACTION/ NURSING RATIONALE RESPONSE &

Subjective findings:
________________________
________________________
________________________
________________________
________________________
________________________
________________________
Objective findings:
________________________
________________________
________________________
________________________
_______________________
Focus/ Nursing Dx: (PE/S)
________________________
outcomes
STG: within ______hour/s of
NI the patient will be able to
______________________
_______________________
_______________________
_______________________
as manifested/evidenced by:
_______________________
_______________________
_______________________
LTG: after ____ hrs/days of
NI the patient will be able to:
_______________________
_______________________
as manifested by:
______________________
INTERVENTIONS EVALUATION
Dxtc: After ______hr/s of NI, the patient
was able to
________________
_________________ ___________________________
________________ as manifested by ____________
_________________
________________ ___________________________
_________________
________________ ___________________________
_________________
STG: fully/partially/un MET
________________
Txc:
________________
_________________
________________
_________________ After ______hr/s of NI, the patient
________________ was able to ___________
_________________
___________________________
________________
_________________ ____________as manifested by
________________
Edx: ___________________________
________________ ___________________________
_________________
________________ ___________________________
_________________
________________ STG: fully/partially/un MET
_________________
________________
_________________

FEEDBACK: CONGRATULATIONS, you have just shown how prepared you are in meeting your patient’s needs. If
this continues, expect that a lot of your patient will be smiling and thanking you for saving their lives.

COLLABORATION
Activity 7: As a future nurse you should be able to work with your co-nurses and other health care professionals and form a team sharing
knowledge and resources to solve or provide patient care.
- Concepts: referral to physician, respiratory therapist/PT, nutritionist, family planning, rehab, psyche etc.
- Ex of scenario: You want to emphasize on breastfeeding the neonate, to whom will you coordinate the diet of the mother
Prepared by: Brando B. Badecao
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- Justify (in 3-5 sentences)

FEEDBACK: WELL DONE! You have contributed in making the health care team working as one for the benefit of the patient.

ETHICO-MORAL-LEGAL CONCERNS (may be added for 2nd years last ward duty)
Activity 8: These principles concern the ethics of caring rather than 'curing' by exploring the everyday interaction between you as a nurse
and the person in your care.
- Concepts: justice, beneficence, nonmaleficence and autonomy
- Ex: If you injected the vaccines the wrong technique
- What will be your nursing action?
- Justify (in 3-5 sentences)
FEEDBACK: WELL DONE! you are almost done, its not time to give up. Take a deep breath, cool down, and proceed. Now summarize
what you have done by formulating the concept map/table.

ACTIVITY 9:
Make or Trace the physiology from normal conception to delivery to a neonate
Should you have clarifications I am a text away.
Good luck.

Reference: Textbooks /Online resources allowed but should not come from blogs, Wikipedia,

Feedback: Congratulations, you are helping yourself achieve your dream of becoming a nurse. Keep up
the good work.

COMMUNICATION
Activity 10: Your shift is about to end, using ISBAR (a patient safety communication structure that aids simplified, effective, structured and
anticipated communication between healthcare personnel). Fill in your end of shift report to help guide the incoming student nurse. n
Identify yourself: your name: _________________ role: student nurse ward/area: ________________
Situation: What is your patient’s name, age & gender, current situation/status (stable but in danger of deterioration, unstable), concern
or your observations, what needs to monitor/observe (ex; abnormal VS, labs, active clinical signs/symptoms)
Background: Give the relevant details such as presenting problems and clinical history that will help the incoming staff interpret the
situation easily; may also include meds / procedures already administered
s
Assessment: What is your assessment? (Base it on your observation on your patient during your shift what is his/her current condition,
risks & needs).
Recommendation: What do you recommend being done to correct the situation? Be clear about what you are requesting. (e.g
transfer/review/treatment? When should it happen?

Feedback: CONGRATULATIONS, you have carried out your task. I will be getting back to you in after I have read your output.

Prepared by: Brando B. Badecao

REMINDER: REPRODUCTION/SHARING OF THIS MODULE OR ANY OF ITS PART/S WITHOUT YOUR
INSTRUCTOR’S CONSENT IS STRICTLY PROHIBITED
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Prepared:

Rodessa Lynn D. Canillas, RM, RN, MAN

Clinical Instructor

Jason C. Delson, RN, EMT

Clinical Instructor

Noted:

Brando B. Badecao, RN, MAN

Clinical Coordinator

Approved:

John Michael P. Jarata, RN, MAN

Dean

Note: can be same format for online case analysis/presentation

Feedback: SMS, private message, zoom conference (immediate)

NCM 107: CARE OF MOTHER, CHILD & ADOSLESCENT (well client)

Prepared by: Brando B. Badecao

REMINDER: REPRODUCTION/SHARING OF THIS MODULE OR ANY OF ITS PART/S WITHOUT YOUR
INSTRUCTOR’S CONSENT IS STRICTLY PROHIBITED
Page 7 of 7