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Clinical Decision-making Diagnosis and Plan

Clinical Decision-making Diagnosis and Plan

Clinical Decision-making Diagnosis and Plan
Clinical Decision-making Diagnosis and Plan
Clinical Decision-making Diagnosis and Plan

Subjective Data

The patient, in this case, was a newborn baby girl born at 37 weeks gestation through Caesarian-section. At delivery, the child weighed 2.0 kg, she measured 46.0 cm by length and a head circumference of 33.5 cm. Following a study done by Perez & Mendez (2019), the weight of the baby was below average (3.5kg). However, the head circumference was normal and within the average range (35.0cm +/- 2) (Perez & Mendez, 2019). The length of the child was shorter than the standard average 50cm. The baby’s Apgars scores were 8 and 9, which were higher than the standard values of 0 to 2. The child was observed to have a length of 46.0cm, which was shorter than normal average length of 50cm (Perez & Mendez, 2019). Clinical Decision-making Diagnosis and Plan

The patient was referred to the NPP by a transitional nurse after discovering that her axillary temperature and bedside glucose were 96.5oF (35.8oC) and 17, respectively. According to Razak (2019), the axillary temperature was below the normal range of 36.5–37 °C (Razak, A. (2019). The patient’s bedside glucose was lower than normal 40mg/dL (2.2mmol/L) (Student nurse political action day, 2019).

An occurrence of ROM was observed during birth, and the fluid was clear. The baby needed drying and normal care after delivery. The baby was placed on her mother’s chest, then oriented to the skin to skin contact. The transitional nurse contacted the NICU after measuring the child’s axillary temperature and glucose level an hour after delivery. During delivery, the mother was 35 years, she was a P2 and a G2, with a significant prenatal Caesarian-Section due to progression failure. She experienced chronic hypertension, coupled with superimposed preeclampsia. In her pregnancy, she took prenatal vitamins and labetalol. During the pregnancy, she began prenatal care within her first trimester and was consistent with an obstetrician. She has a husband and lives together with their son, aged five years. At presentation, she had a headache and a significant blood pressure evaluation. Upon arrival, she was admitted to the L & D, where blood pressure elevation persisted. She first introduced to magnesium sulfate following a c-section. Her lab results were as indicated below;


Blood Type RPR Hepatitis B HIV Rubella GBS
A+ (-) (-) (-) Immune (-)

Objective data

The infant was transferred to the NICU for more evaluation. The physical examination revealed that she was active, a tone was appropriate for the 37 weeks gestational age infant. The newborn was jittery. Her work breathing indicated no increase and no murmur. The abdomen of the infant was flat, soft, and didn’t indicate hepatosplenomegaly. She exhibited adequate perfuse with equal femoral as well as branchial pulses. The patient had no dysmorphic or abnormal features. Vital signs of EMR were noted, such as the axillary temperature of 96.8oF, respiratory rate 52, oxygen saturation of the room 97%, blood pressure 60/40, and heart rate of 154. Clinical Decision-making Diagnosis and Plan

Primary Diagnoses: Infant Hypoglycemia

The patient was diagnosed with infant hypoglycemia. Following the presented history, the patient was not well fed. An hour after birth, the tests for glucose level indicated a bedside glucose level of 17. According to a study by Gandhi, (2017), a blood glucose level below 50 mg/dL within first <48 hours after birth in infants translates to hypoglycemia. Other symptoms of hypoglycemia include jitteriness, which was also exhibited by the infant (Sunehag & Haymond, 2018). Diagnosis 1 The diagnosis herein would be confirmed by taking blood sugar tests using a glucometer. The recommended remedy was glucose blood infusion via the IV method. The assessment would be conducted in 20 minutes intervals. The appropriate infusion would be at 4-6 mg/kg/min. Diagnosis 2 Another possible diagnosis was hypothermia. A physical examination of the patient loss of heat energy from the body than it was readily produced. The hypothermia patients exhibit a significant drop in the body temperature such as 95F. Diagnosis 3 Although hyponatremia has overlapping symptoms with hypoglycemia in newborns. A serum sodium concentration test would be used to rule out its presence. Furthermore, other supportive symptoms were not exhibited for hyponatremia, such as dehydration, weakness, and vomiting. In case hyponatremia would be confirmed, an IV infusion of saline solution 5% D/W/0.45% to 0.9% would be used for treatment (Ahmed, 2018). Rule-out diagnoses: Sepsis In case of sepsis, the body normally releases the chemicals into the blood stream to fight the presence of infection. The diagnosis of sepsis would follow the blood tests to identify the presence of various anti-infection agents in the blood such as CD4+ and T-cells. The diagnosis of sepsis was out ruled due to the absence of supporting historical and symptomatic information (Rhodes, Evans, Alhazzani, Levy, Antonelli, Ferrer, & Rochwerg, 2017). Clinical Decision-making Diagnosis and Plan Treatment Plan The infant should be placed under NICU care for more evaluation. While in the NICU, the treatment for hypoglycemia will be initiated and continued until a stable blood sugar level is maintained. Nutrition/FEN Oral nutrition through breastfeeding. Breast milk would be essential in the provision of different nutrients as well as antibodies. Despite the technicality of the NICU environment, the mother will be allowed to breastfeed the child to enhance growth and development. The colostrum produced within the first few hours after birth is an important source of antibodies, minerals, and nutrients (Gertz & DeFranco, 2019). Health Maintenance The health maintenance approach, in this case, would be done via frequent/regular monitoring of the blood glucose and axillary temperature levels. Once a stable axillary temperature close to the normal has been achieved, the treatment will be stopped. Health maintenance will also be done by the management of the blood glucose level to remain within the allowable range, above 40mg/dL, the stoppage of the treatment plan will (Gertz & DeFranco, 2019). Reference Ahmed, R. G. (2018). Does maternal antepartum hypothyroidism cause fetal and neonatal hyponatremia. ARC Journal of Diabetes and Endocrinology, 4(1), 2018. Gandhi, K. (2017). Approach to hypoglycemia in infants and children. Translational pediatrics, 6(4), 408. Gertz, B., & DeFranco, E. (2019). Predictors of breastfeeding non‐initiation in the NICU. Maternal & child nutrition, 15(3), e12797. Perez, B. P., & Mendez, M. D. (2019). Routine Newborn Care. In StatPearls [Internet]. StatPearls Publishing. Razak, A. (2019). At what weight should preterm infants be transferred from incubator to open cot?. Archives of disease in childhood, 104(7), 707-710. Rhodes, A., Evans, L. E., Alhazzani, W., Levy, M. M., Antonelli, M., Ferrer, R., ... & Rochwerg, B. (2017). Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: . Intensive care medicine, 43(3), 304-377. Student nurse political action day 2019. (2019). The Nursing Voice, 7(1), 1-1,4. Retrieved from https://fir.tesu.edu:2128/docview/2243422469?accountid=40921. Sunehag, A., & Haymond, M. W. (2018). Approach to hypoglycemia in infants and children. CDM_Instructions___Rubric_(Revised_3.4.20) Scenario_for_CDM_N5204_Spring_2020 220872 Clinical Decision-making Diagnosis and Plan

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