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Clinical Reasoning Case Study

PART 1

Introduction

A newly born baby girl named Baby R was diagnosed with myelomeningocele after she was delivered through a caesarian delivery. This is a medical condition in which the bones of the spinal cord are not developed properly (Medline Plus, 2020). The Baby R was transferred to the Neonatal Intensive Care Unit (NICU) and kept in an open radiant warmer. The next day, Baby R was taken to the operation room for surgery to treat myelomeningocele, and then she was shifted to Post-Anaesthetic Care Unit (PACU). After some time, the baby was shifted back to NICU, but in the NICU, the open radiant warmer started alarming as baby's temperature dropped to 35 °C. It was also observed that the suture was not properly intact, and the baby's oxygen saturation rate also decreased. Talking about Baby R's family history, her mother was at the women's hospital, and her father visited her but was confused about her medical condition. This paper aims at understanding the given case study using the steps of the Clinical Reasoning Cycle. It also includes a CRC or pathophysiology concept map that can be used to understand the case study effectively.

Collecting Clues/information

The baby's weight after birth was 3.5 kg, which is normal; her blood pressure was normal at 67/33 mm Hg, and her pulse rate was 173. Respiration rate was 52 breathes per minute, and the body temperature was 37.1 °C, which is the average temperature of a newborn baby (The University of Iowa, 2020). The nurse in the NICU also observed that baby's oxygen saturation rate was 95%, which falls under the normal oxygen saturation rate. The pathology results of Baby R revealed that her Na+ concentration was 143, calcium concentration was 101, potassium ion concentration was 6.4, C-reactive protein (CRP) was 5, Hb was 184 while WCC was 22.8. Baby R was given cefazolin 140 mg IV around 30 minutes before surgery.

The PACU nurse recommended the NICU nurse to give Morphine infusions at 10-20mcg/kg per hour, Paracetamol IV 52.5mg after every six hours of 24 hours of post-surgery and 100% intravenous maintenance fluids. Some of the other post-operative orders instructed by the PACU nurse to the NICU nurse include the use of open radiant warmers to monitor the baby's body temperature, use of the pressure-reducing mattress for the baby and to keep the baby in Trendelenburg position.

Administration of IV fluid and antibiotics, accessing urine outputs of Baby R after every two to four hours, and cleaning the paddings placed under the diaper area was also recommended as a post-operative order by the PACU nurse. Regular monitoring of fronto-occipital circumference (FOC), and maintaining a latex-free environment are also parts of post-operative surgery. However, it was observed that when Baby R was shifted in the NICU, the open warmer in which the baby was kept started alarming as the baby's temperature dropped to 35 °C, which is below normal body temperature. The oxygen saturation also dropped from 95% to 74%, the respiratory rate decreased from 52 to 25, and the heart rate also reduced to 85 from 173. Moreover, the suture that was placed during the surgery was also not intact, and all these are harmful to the baby's health.

The newly born infants that have any type of health complications are kept in NICU to monitor their health continuously. The IV or intravenous catheter is used by the registered nurses to provide medicines as well as fluids to the newborn (Kids Health, 2019). According to the case study, the Baby R was given 140 mg cefazolin IV thirty minutes before the surgery. The PACU nurse has included IV fluids and IV antibiotics in the postoperative orders. As per The Royal Children's Hospital, Melbourne (2019), the IV therapies in the newborns require careful monitoring. The unwell infants are provided with 2/3 maintenance rate, which is 13 for the children below 5 years of age.

This reflects that Baby R should also be provided with 2/3 maintenance rate as she has health complications. The weight of all the babies must be recorded before and after the use of IV therapies, and any fluctuation must be monitored carefully. The electrolyte and glucose level of infants undergoing IV therapies must also be monitored carefully as it will affect the dose of drugs that are given through IV therapies. The given information in the case study is that 10 mL of sterile water is taken to a 1 g of the vial to make 100 mg per 1 ml of drug dose. The millilitres of drug that can be drawn from the dose is calculated below:

10 ml = 1000 mg

1 ml = 1000/10

1 ml =100 mg/ml

Thus, 1 ml of the drug should be drawn from the dose.

The shaded portion in the diagram given below represents the millilitres of drug dose that can be drawn through the syringe.

image illustrates the millilitres of drug dose that can be drawn through the syringe

The patient in the given state is a newly born infant who does not have any perceptions right now. However, the patient's father is confused as he lacks information about the patient's medical conditions and other health complications. He has tried to study myelomeningocele but stills lack accurate information about it. This represents that he is not having a good knowledge of diseases and health problems and requires assistance from nurses to understand myelomeningocele. Baby's father resists in interacting and touching the baby due to her medical complications. It can be analyzed from the case study that the baby's father is caring towards her as he tries to collect more information about her health conditions.

Moreover, Baby's mother has not seen her child because she has been hospitalized to the Women's hospital to recover from a caesarian delivery. The patient, Baby R, has to undergo surgery right after birth, which can have a negative impact on her parent's psychological conditions. This can cause emotional stress on the baby's parents and other family members. It can also be observed from the case study that the baby has coped up very nicely with the operation. This is because she has handled several medications, treatments, and one surgery just after her birth. This can be analyzed from the fact that the PACU nurse informed the NICU nurse that baby was very cooperative during the surgery.

PART 2

flow chart shows Pathophysiology Concept Map

References

Ergenekon, E. (2016). Therapeutic hypothermia in neonatal intensive care unit: Challenges and practical points. Journal of Clinical Neonatology, 5(1), 8-17. DOI: 10.4103/2249-4847.173271

Kids Health. (2019). When your baby's in the NICU. Retrieved from https://kidshealth.org/en/parents/nicu-caring.html

Mank, A., Zanten, V. A. H., Meyer, P. M., Pauws, S., Lopriore, E. & Pas, B. A. (2016). Hypothermia in preterm infants in the first hours after birth: occurrence, course and risk factors. PLoS One, 11(11). DOI: 10.1371/journal.pone.0164817

Mayo Clinic. (2020). Hypothermia. Retrieved from https://www.mayoclinic.org/diseases-conditions/hypothermia/diagnosis-treatment/drc-20352688

Medline Plus. (2020). Myelomeningocele. Retrieved from https://medlineplus.gov/ency/article/001558.htm

Nitzan, I., Goldberg, S., Hammerman, C., Bin-Nun, A. & Ruben, B. (2019). Effect of rewarming in oxygenation and respiratory condition after neonatal exposure to moderate therapeutic hypothermia. Pediatrics & Neonatology, 60(4), 423-427. https://doi.org/10.1016/j.pedneo.2018.10.001

The Royal Children's Hospital, Melbourne. (2019). Clinical Practice Guidelines - Intravenous Fluids. Retrieved from https://www.rch.org.au/clinicalguide/guideline_index/Intravenous_Fluids/

The Royal Children's Hospital, Melbourne. (2019). Therapeutic hypothermia in the neonate

The University of Iowa. (2020). PICU Handbook. Retrieved from https://uichildrens.org/health-library/pediatric-critical-care-reference-guide-picu-charts

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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