Liam is a newborn boy who was born to Ruth and Ben. Ruth and Ben have nine children. Both parents work from home and their income comes from selling produce grown on their land at local farmer’s markets

QUESTION

Liam is a newborn boy who was born to Ruth and Ben. Ruth and Ben have nine children. Both parents work from home and their income comes from selling produce grown on their land at local farmer’s markets.

Liam was born at home with a midwife present and was assumed to be born at full-term. Ruth did not have an ultrasound during her pregnancy, but the midwife did do pregnancy checks in the home every 4-6 weeks. Ruth did not have any complications during her pregnancy.

On her initial assessment after birth, the midwife auscultated a heart murmur and noted that Liam’s respiratory rate was 80-90 per minute. She also noted that he was having trouble breastfeeding and seemed to breath even faster when he was nursing. Several hours after birth, Liam’s breathing did not improve and he was very sleepy. The midwife told Ruth that Liam should go to the hospital to be evaluated. Ruth was very hesitant to go to the hospital.

The midwife spoke to Ruth and explained that she was very concerned about Liam’s breathing. Ruth and Ben agreed to take Liam to the community hospital.

The family does not have a car but they are able to borrow one from Ruth’s sister who will also watch the other children.

Ruth and Ben arrive to the hospital with Liam. They have a distrust of the medical system and fear that Liam will undergo unnecessary medical procedures. They are also very worried about the hospital vaccinating Liam. They also have concerns about cost as they currently have no medical insurance.

Liam’s vital signs are as follows:

HR – 192

RR – 72

Temp – 97.2 F

Oxygen saturation on room air – 92-94%

Blood pressures:

Left arm 66/32

Right arm 65/28

Left leg 72/40

Right leg 74/42

Weight – 2.58kg

Length – 19 inches

On exam Liam is in respiratory distress. He has subcostal retractions that worsen when he is crying. His skin is cool and mottled.

A):
1: What are the main factors that brought this patient to seek care?
2: Present Medical History
3:Past Medical History
4: physical Assessment
5: What else do you want to know

B):
1:Assessment: (What stands out?)Vital Signs, Inspection, Palpation, Percussion, Auscultation
2: Nursing Diagnosis: identify 3 main nursing concerns for this patient
3:Interventions: What are your 3 most nursing interventions
4:Evaluation: How will you know that your interventions worked?
Reference: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 15th Ed
Reference: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing
Nursing school Med-surg assignments

ANSWER

Patient Information

Main Factors for Seeking Care

Liam’s parents, Ruth and Ben, sought medical care due to several concerning symptoms observed by the midwife during the initial assessment after birth. These symptoms include a heart murmur, rapid respiratory rate (80-90 breaths per minute), difficulty breastfeeding, and increased respiratory distress during nursing. Additionally, Liam’s condition did not improve, and he appeared very sleepy, prompting the midwife’s recommendation to go to the hospital for evaluation.

Present Medical History

At the time of presentation, Liam’s medical history includes being a newborn boy born at home with a midwife present. There were no known complications during Ruth’s pregnancy, as she did not have any ultrasounds. The midwife provided routine pregnancy checks at home every 4-6 weeks.

Past Medical History

Since Liam is a newborn, there is no past medical history available for him.

Physical Assessment

Upon examination, Liam is in respiratory distress, characterized by subcostal retractions that worsen during crying. His skin is cool and mottled, indicating possible circulation issues. Vital signs reveal tachycardia (heart rate of 192 BPM) and tachypnea (respiratory rate of 72 breaths per minute). His oxygen saturation on room air is between 92-94%, which is slightly below the normal range. Blood pressure measurements show low values in all limbs, with the left arm having the lowest reading (66/32 mmHg).

Additional Information

Additional information that would be helpful includes the maternal health during pregnancy, prenatal care history, and any maternal risk factors for potential congenital heart defects.

Nursing Assessment

Assessment Findings

The most significant assessment findings include Liam’s rapid respiratory rate and subcostal retractions, indicating respiratory distress. His cool and mottled skin suggests possible perfusion issues. The tachycardia and low blood pressure readings in all limbs raise concerns about cardiovascular stability.

Nursing Diagnoses

Three main nursing concerns for Liam could be:
Impaired Gas Exchange related to respiratory distress and tachypnea.
Ineffective Tissue Perfusion related to possible cardiovascular compromise and low blood pressure readings.
Risk for Altered Parent-Infant Attachment related to the family’s distrust of the medical system and reluctance to seek care.

Nursing Interventions

The three most important nursing interventions would be:
Providing Respiratory Support: Administering supplemental oxygen, monitoring respiratory status, and implementing measures to improve gas exchange, such as positioning and suctioning if necessary.
Enhancing Perfusion: Monitoring blood pressure and circulation, and initiating interventions to optimize tissue perfusion, such as keeping the baby warm and maintaining adequate hydration.
Establishing Trust and Education: Communicating with Ruth and Ben to address their concerns, providing education about Liam’s condition and the necessity of medical interventions, and involving them in decision-making.

Evaluation

The effectiveness of nursing interventions will be evaluated by monitoring Liam’s response to treatment and interventions. Improvement in respiratory distress, stabilization of vital signs, and a gradual improvement in oxygen saturation would indicate positive outcomes. Additionally, building trust and open communication with the family would contribute to their understanding and acceptance of the medical care provided.