• Internal Code :
  • Subject Code : NSG3102
  • University : Holmesglen institute
  • Subject Name : Nursing

Case Study: Clinical Reasoning

Introduction

The baby girl R was brought to the neonatal intensive care unit after being diagnosed with Myelomeningocele which was discovered in-utero. The baby was delivered by caesarean delivery and was accompanied by her aunt and father while the mother remained in the hospital. The father had less health literacy regarding the condition but made an effort to understand the condition for which he sought internet but was confused about the condition especially the difference between Myelomeningocele and meningocele. Myelomeningocele is a type of spina bifida which is a birth defect in the spine where the spinal cord fails to close before birth and requires surgical management (Heuer et al., 2017). This leads to protrusion of the spinal cord and meninges in the back of the child (Heuer et al., 2017). This is different from meningocele where there is a presence of fluid-filled sac in the gap of the spine and causes fewer problems compared to Myelomeningocele (Brown et al., 2017). Baby Girl R was operated and the surgery was uneventful and she is transferred to the neonatal intensive care unit.

Collection of Cues

When the Baby girl R was admitted it was seen that her blood pressure was 67/33mmHg, her pulse was 173 beats per minute, her respiratory rate was 52 breaths per minute, the temperature was seen to be 37.10C. The oxygen saturation was normal as it was 95% and the weight was 3.5Kg. Her breath sounds were clear, pupils were 2cm and showed brisk reaction though she felt sleepy, she squirmed and fussed while checking her pupils. The capillary refill time was less than 2-3 seconds which is seen to be normal. The baby showed clubfeet bilaterally and signs of acrocyanosis which means that the peripheral circulation of the body was inadequate and she was not receiving proper oxygen. The following day the baby was operated upon and she was administered anesthesia cefazolin 140mg intravenously and this was administered 30 minutes before the surgery.

The surgery was uneventful and as the patient was recovering properly the patient was deemed fit to return to the neonatal intensive care unit. The patient was to be given a morphine infusion at the rate of 10-20mcg/kg/hr for pain management along with paracetamol which was given intravenously as 52.5mg, 6 hourly for twenty-four hours. It was instructed that the patient was to be maintained with 100% intravenous fluid. For complete recovery, it was required that the baby was kept in an open warmer in a Trendelenberg position with the use of proper props for positioning of the patient. The surgical site should be maintained to be sterile with normal saline and it should be monitored every two to four hours. Fluid maintenance and administration of antibiotics are to be given intravenously, padding to be kept under the diaper area should be kept clean and monitored frequently and the environment should be maintained as latex-free.

As per the medication calculation that is provided in the case study the quantity that needs to be drawn up is 1mL. (The part in the syringe needs to be shaded by the client). Though the father of the patient is present and is asking for the update it is seen that neither does he look of touches the child nor interacts with her. This can affect the child in terms of recovery and health outcome.

Identify the Issue

At present, it is seen that the temperature of the patient is reduced and it is 350C, the suture at the site of surgery is not intact and the oxygen saturation has reduced to 71%. The respiratory rate and pulse of the baby have also reduced as they are 25 breaths per minute and 85 beats per minute. The normal heart rate of a newborn baby should be between 100-150 beats per minute which gradually reduces as the baby grows (Sharma, 2017). The normal respiratory rate of a newborn baby should be in the range of 30-60 breaths per minute (Raj et al., 2018). From the signs and current condition of the patient, it can be seen that nursing problems are hypothermia, hypoxia and integrity of the surgical site as well as the risk of infection as the suture has been displaced.

Establishment of Goals

The goals in case of healthcare are generally made in the form of SMART goal such that they are specific, measurable, achievable, realistic and timely (Sibley et al., 2020). The patient has reduced temperature if it reduced further it can cause severe hypothermia, similarly, hypoxia can cause affect the functioning of major organs including the brain. The integrity of the surgical site is required as it can affect the spine, sterility is affected and can act as a portal for the entry of infectious substances. The first goal would be to increase the body temperature of the patient to the normalcy of 36.40C by the administration of heat within one hour. The second goal would be to increase the oxygen saturation of the patient by the administration of oxygen and it should be achieved within one hour as well. The third goal would be to re-suture the surgical site by a doctor after ensuring to effectively clean the site and is to be done at the earliest. The pediatric doctor responsible for the care of the patient should be informed immediately the orders for the treatment is to be obtained before the administration of any intervention. Once the interventions are properly administered to the patient, the respiratory rate as well as heart rate can revert to normal.

Evaluation of Outcomes

The vital signs of the patient need to be monitored continuously to make sure that the intervention was effective. After administration of oxygen, the pulse oximeter can be used continuously for the evaluation of oxygen saturation and it has to be made sure that there is no over-saturation with oxygen (Askie et al., 2018). The temperature of the patient can be evaluated with the use of a tympanic thermometer. The surgical site should be evaluated every hour to make sure sutures are present and there is no bleeding and there less drainage. The mother of the child is not present as kangaroo care can be employed for increasing the temperature as well as regularization of the heart rate (Srinath et al., 2016). The father can be educated and educated regarding the importance of the same and ask him to hold the baby for some time so that a positive health outcome can be achieved.

References

Askie, L. M., Darlow, B. A., Finer, N., Schmidt, B., Stenson, B., Tarnow-Mordi, W., ... & Das, A. (2018). Association between oxygen saturation targeting and death or disability in extremely preterm infants in the neonatal oxygenation prospective meta-analysis collaboration. JAMA319(21), 2190-2201. 

Brown, E. C., Gupta, K., & Sayama, C. (2017). Neurosurgical management in lateral meningocele syndrome: Case report. Journal of Neurosurgery: Pediatrics19(2), 232-238. 

Heuer, G. G., Moldenhauer, J. S., & Adzick, N. S. (2017). Prenatal surgery for myelomeningocele: Review of the literature and future directions. Child's Nervous System33(7), 1149-1155. 

Raj, A. A., Preejith, S. P., Raja, V. S., Joseph, J., & Sivaprakasam, M. (2018). Clinical Validation of a Wearable Respiratory Rate Device for Neonatal Monitoring. In 2018 40th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC),1628-1631.

Sharma, D. (2017). Golden hour of neonatal life: Need of the hour. Maternal health, neonatology and perinatology3(1), 16. 

Sibley, C., Ayers, C., King, B., Browning, T., & Kwon, J. K. (2020). Decreasing patient dwell times for outpatient cardiac nuclear medicine studies: The benefits of SMART goals, scope limitations, and society guidelines in quality improvement. Current Problems in Diagnostic Radiology.

Srinath, B. K., Shah, J., Kumar, P., & Shah, P. S. (2016). Kangaroo care by fathers and mothers: comparison of physiological and stress responses in preterm infants. Journal of Perinatology36(5), 401-404.

Remember, at the center of any academic work, lies clarity and evidence. Should you need further assistance, do look up to our Nursing Assignment Help

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