Case Presentation

Charish Dwayne Pondales

Case Abstract
This is the case Baby Boy Ydel New Born,
Learning Objectives
oTo Identify the right type of care for the patient
through the Patient’s profile.
oAnalyze the physical status of the patient through
Gordon’s and Physical Examination.
oInterpret the findings in the laboratory results to
identify the condition affecting the patient.
o Classify effective drugs that works best for the patient.
oFormulate an effective Nursing Care Plan that fits well
to the client’s needs.
Biographical Data
o Patient’s Name: Baby Boy 2A
o Age and Gender: Newborn, Male
o Date of delivery and time: February 22, 2020;
4:52pm
o vital signs: T: 36.7 degrees Celsius, P: 142 bpm, O2
Sat: 100, RR: 63bpm
oAOG: By weeks: 35 weeks 6 days By SCORE: 35-36
weeks
oWeight: 1.550Kg
oLength: 37cm
o Diagnosis: Live preterm male 1st of twin delivered
Gordon’s health pattern:
Activity and rest Pattern:
o
 Physical Examination
o height and weight are proportional
o with obvious signs of illness ( hence
pale)
oPale color of conjunctiva
oNormal breathing sounds
oResponsive to voice tones
oPalpable brachial and radial pulse
oNormal heart sounds
Pathology and Physiology of the
Uterus
Refer to the whiteboard
Treatment
Standard:
o
Treatment
Complete Blood Count February
13,2020
Laboratory Results Normal Values
Hemoglobin 12g/l
Hematocrit 37.0-47.0
WBC Count 5000-10,000
RBC Count 3.7-5.00
Platelet Count 150,000-400,000
Neutrophils 50-70.0
Lymphocytes 20-40
Monocytes 0.0-7.0
Segmenters 55-65%
Stabs 3-5%
Complete Blood Count February
15,2020
Laboratory Results Normal Values
Hemoglobin 8.1 12g/l
Hematocrit 22.9 37.0-47.0
WBC Count 10,700 5000-10,000
RBC Count 2.72 3.7-5.00
Platelet Count 228,000 150,000-400,000
Neutrophils 81.0 50-70.0
Lymphocytes 14.0 20-40
Monocytes 5.0 0.0-7.0
Segmenters 90% 55-65%
Stabs 3% 3-5%
Complete Blood Count February
16,2020
Laboratory Results Normal Values

Hemoglobin 11.6 12g/l

Hematocrit 31.6 37.0-47.0

WBC Count 7,200 5000-10,000

RBC Count 3.69 3.7-5.00

Neutrophils 71.0 50-70.0

URINALYSIS February 15,2020
Laboratory Results Normal Values
Color Dark Yellow Straw Yellow

Transparency Slightly Turbid Clear

pH 6.5 5.50-900
SP Gravity 1.005 1.015-1025
Sugar Negative Negative
Urobilinogen Negative Normal
Ultrasound February 16,
2020
Trans Vaginal
Endometrium: 1.9 Hyperechoic
Uterus: Anteverted
Drug Study
               
Name of Drug Classification Dosage Route of Mechanism of Indication Contraindicati Nursing
(Generic and Administration action (general on responsibilitie
Brand) indication, the s
  specific
indication to
patient)
 
Ceforuxime Antibiotic 750mg IV -inhibits -antibiotic - -Monitor the
(zeger) (2nd gen) bacterial cell Hypersensitivit patient IV fluid.
wall synthesis y to -Monitor
by binding to cefuroxime or patient's vital
one 1 or more other signs
of the cephalospovisi
penicillin- s
binding
proteins (PBPs)
which in turn
inhibit the final
transpeptidatio
n step of
peptidoglycan
synthesis in
bacterial cell
walls, thus
inhibiting cell
wall
biosynthesis
and arresting
cell wall
assembly
resulting in
bacterial cell
Drug Study
               
Name of Classifica Dosage Route of Mechanis Indication Contraind Nursing
Drug tion Administr m of (general ication responsib
(Generic ation action indication ilities
and , the
Brand) specific
  indication
to
patient)
 
Omeprazo proton 40mg IV - -PPI - -Monitor
le pump omeprazo Hypersen the
(Zefron) inhibitors le is a sitivity to patient IV
(PPIs). substitute any fluid.
d proton -Monitor
benzimida pump patient's
zole inhibitor vital signs
gastric
antisecret
ory agent.
 Drug Study
               
Name of Classificatio Dosage Route of Mechanism Indication Contraindica Nursing
Drug n Administrati of action (general tion responsibiliti
(Generic and on indication, es
Brand) the specific
  indication to
patient)
 
Calcium -electrolytes 1 ampule IV -calcium -Supplement Patients with -Monitor
Gluconate gluconate is calcium patient's IV
used to renal calculi fluid.
prevent or or history of -Monitor
treat renal calculi. patient's
negative Conditions intake and
calcium associated output.
balance. It with
also helps hypercalcae
facilitate mia and
nerve and hypercalciuri
muscle a.
performance
as well as
normal
cardiac
function.
Drug Study
               
Name of Classificatio Dosage Route of Mechanism Indication Contraindica Nursing
Drug n Administrati of action (general tion responsibilit
(Generic and on indication, ies
Brand) the specific
  indication to
patient)
 
-class of 50mg IV - - -Asthma, -Monitor
Diphenhydra topical Diphenhydra antihistamin narrow angle mental
mine antihistamin mine is an es glaucoma, alertness,
es used in antihistamin prostatic relief of
the e w/ hypertrophy, symptoms.
treatment of anticholinerg stenosing
pruritus. ic and peptic ulcer,
sedative pyloroduode
effects. It nal
competes w/ obstruction
histamine for or bladder
H1-receptor neck
sites on obstruction,
effector cells porphyria.
in the GI Neonates or
tract, blood premature
vessels and infants.
resp tract. Lactation.
 Drug Study
               
Name of Classificati Dosage Route of Mechanism Indication Contraindi Nursing
Drug on Administra of action (general cation responsibil
(Generic tion indication, ities
and Brand) the
  specific
indication
to patient)
 
Mefenamic Nsaid 500mg Oral Q6 Mefenamic Nsaid Hypersensi -Monitor
acid acid, an vity and CBC and
anthranllic acidic. Blood
acid, is an pressure.
NSAID. It -Monitor
exhibits patient for
analgesic, any allergic
anti reactions
infammator
y and
ati[yretic
properties.
 Drug Study
               
Name of Classificati Dosage Route of Mechanism Indication Contraindi Nursing
Drug on Administra of action (general cation responsibil
(Generic tion indication, ities
and Brand) the
  specific
indication
to patient)
 
Ferrous Iron 1 Tab OD PO Iron helps Anemic Hemosider Note
Sulfate Suppliment the red Patients osis and adverse
(Heme-UP) blood cells hemachro reactions
deliver matics Monitor
oxygen to CBC
the body Monitor
Stool
output

M
 Drug Study
               
Name of Classificati Dosage Route of Mechanism Indication Contraindi Nursing
Drug on Administra of action (general cation responsibil
(Generic tion indication, ities
and Brand) the
  specific
indication
to patient)
 
Metoclopa Antacid/ 10 mg Q8 IV Metoclopa Nausea Patients Note
mide Anti emitic mide is a and with adverse
substitute Vomitting gastrointes reactions
of tinal
benzamide perforation
with hemorrhag
prokinetic e, epilepsy,
and Parkinson
antiemetic disease
properties
 Drug Study
               
Name of Classificati Dosage Route of Mechanism Indication Contraindi Nursing
Drug on Administra of action (general cation responsibil
(Generic tion indication, ities
and Brand) the
  specific
indication
to patient)
 
PRBC Blood 304cc 4-6 IV To Monitor
(Packed component hours replenish drops per
Red Blood red blood minute
Cells) cells from Check the
the blood serial
stream number,
blood type,
expiration
date
Prescribe
as ordered
 Drug Study
               
Name of Classificati Dosage Route of Mechanism Indication Contraindi Nursing
Drug on Administra of action (general cation responsibil
(Generic tion indication, ities
and Brand) the
  specific
indication
to patient)
 
PNSS IVF 1L X 8 IV To Monitor
hours accompany drops per
for Blood minute
transfusion Keep
infusion in
check
Note the
time
infused
Do not
administer
without
doctors
order
 Drug Study
               
Name of Classificati Dosage Route of Mechanism Indication Contraindi Nursing
Drug on Administra of action (general cation responsibil
(Generic tion indication, ities
and Brand) the
  specific
indication
to patient)
 
PLR IVF 1L X 8 IV Replenish Monitor
hours fluid and drops per
electrolyte minute
loss Keep
infusion in
check
Note the
time
infused
Do not
administer
without
doctors
order
Nursing Care Plan
Cues Nursing Rationale Nursing Nursing Rationale Expected
Subjective and Diagnosis Objectives Interventions outcome
objective
Objective Acute Pain related to Pain caused by --Patient will report -Perform a -to help determine -pain decrease from
(+) facial grimace postoperative surgical manipulation satisfactory pain comprehensive possibility of 7/10 to 2/10.
sleep disturbance surgery. operation. control at a level less assessment of pain to underlying positional -(-) facial grimace and
restlessness than 2-4 on a scale include condition or organ controledd actions by
1/10. location,characteristi dysfunction. the patient.
Subjective cs,duration,frequency -use pain rating scale -Normal Vital signs.
“masakit parin, -Patient will exhibit ,quality.. appropriate for age -no allergic reaction
kapag gumagalaw o increased comfort -observe non-verbal and condition. (1/10) in the drug.
tatayo ako pero such as baseline cues -how client holds
kailangan ko na kassi levels for the HR, BP, -monitor patient's body and facial
umuwi para sa mga and respiration pain scale and vital expressions.
anak ko” relaxed muscle tone signs. -tp know the patient's
as verbalized by the for body posture. -encourage patient in improvements.
patient a comfortable -to give patient a
-Patient follow position. comfortable position.
prescribed -administer -patient could have
pharmacological mefenamic acid as allergies or undesired
regimen. prescribed by the reactions from the
doctor. drug, it is important
-Patient will -Notify the physician to notify the
verbalized method for any adverse physician
that provide relief. effects immediately.
regardingdication.
Nursing Care Plan
Cues Nursing Rationale Nursing Nursing Rationale Expected
Subjective Diagnosis Objectives Interventio outcome
and ns
objective
Objective: risk for The patient Patient will Increase -To give Patient is aware
(+)facial perioperative requested for know how to awareness of awareness to for any risks
grimace positioning Discharge manage pain or potential injury. the patient and
Waddling gait injury related against medical injury. about potential consequences
slowness to post advice which injuries. toward her
operative can lead to an Patient will Assess the request.
surgery injury. understand the patient's -To asses the
Subjective: manifested by risks for any response to the patient's Patient will
“masakit pa po pain and injury. medication or understanding report any
kapag muscle any discomfort and discomfort or
naglalakad weakness. Patient will and report it to consciosness. potential
pero kailangan comply for the the physical. injuries after
ko na umuwi advised check discharged.
para sa mga up by the Evaluate
anak ko” as physician. environmental
verbalized by conditions/safe
the patient ty issues.
Nursing Care Plan
Cues Nursing Rationale Nursing Nursing Rationale Expected
Subjective Diagnosis Objectives Intervention outcome
and s
objective
Objectives: Risk of Infection ↑ of WBC and ↓ Short Term: I: Assess causative -to know the Patient
(+) signs of related to og hemoglobin Patient will factors for possible causes understand the
bleeding iadequate is a sign of verbalize infection. for infection. diferent causes
increase of WBC secondary understanding of and the possible
infection.
10,700 defenses risk factors. Observe for -to monitor any risk for infection.
manifested by ↓ localize signs of risk of infection.
hemoglobin and Demonstrate infection at Normal WBC and
↑ WBC. techniques, surgical wounds. hemoglobin.
lifestyle changes -for easy and fast
to promote safe Assess and assessment for
environment. document skin any risk infection.
condition, noting
Long Term: inflammation and
Patient will drainage. -as an antibiotic
identify
interventions to D: Administer
prevent risk of cefuroxime as
infection. prescribed by the
doctor.
DISCHARGE PLAN