Term newborn - Nursing Case Study

Pathophysiology

• Primary mechanism: In the first moments of life, a term newborn must transition from relying on the placenta for oxygen and nutrient supply to independent breathing and feeding. This involves the closing of fetal blood vessels and openings (like the ductus arteriosus and foramen ovale), and the initiation of the baby's own respiratory and digestive systems.

• Secondary mechanism: Temperature regulation is crucial in a newborn. Unlike in utero, the baby now needs to maintain its own body temperature. This is typically achieved through non-shivering thermogenesis, primarily in the brown adipose tissue. However, due to high surface area to volume ratio, newborns are prone to heat loss and hypothermia.

• Key complication: Jaundice is common in term newborns due to the breakdown of excess red blood cells after birth, leading to increased bilirubin levels. The immature liver may struggle to eliminate bilirubin effectively, leading to jaundice. If severe, it can lead to Kernicterus, a type

Patient Profile

Demographics:

Newborn, male, not applicable occupation

History:

• Key past medical history: None, term newborn

• Current medications: None

• Allergies: None known

Current Presentation:

• Chief complaint: Regular check-up

• Key symptoms: None, baby is feeding well and has regular bowel movements

• Vital signs: Weight 3.4kg, Heart rate 130 beats per minute, Respiratory rate 40 breaths per minute, Body temperature 36.8 degrees Celsius

Section 1

Initial Assessment Findings:

During the initial physical assessment, the baby appeared generally well with normal skin color and was responsive to stimuli. His anterior fontanelle was flat and soft, and no murmurs were heard upon cardiac auscultation. However, the pediatric nurse noticed a slight yellow tinge to the baby's skin, particularly in the face and chest area, suggesting mild jaundice. The baby's abdomen was soft, and bowel sounds were present and normal. The baby's cry was strong, and he was moving all limbs equally. Reflexes were intact and age-appropriate.

Change in Patient Status:

After 48 hours, the yellowish discoloration of the skin had progressed downwards to involve the abdomen, arms, and legs, indicative of an increasing bilirubin level. The newborn continued to feed well and had regular bowel movements. His weight was stable at 3.4 kg, heart rate at 130 beats per minute, respiratory rate at 40 breaths per minute, and body temperature at 36.8 degrees Celsius. The baby remained alert and active but was slightly more irritable. A transcutaneous bilirubin test was ordered to assess the extent of the jaundice.

Section 2

New Diagnostic Results:

The transcutaneous bilirubin test came back with a level of 15 mg/dL, confirming the diagnosis of mild jaundice. This level, while not severe, is higher than expected for a term newborn at 48 hours of age. The pediatrician orders a comprehensive metabolic panel (CMP) to assess liver function and a complete blood count (CBC) to rule out hemolytic anemia, which might be contributing to the elevated bilirubin level.

Response to Interventions:

The newborn was placed under phototherapy using a blue light, a common treatment for jaundice in newborns. The blue light helps to break down the bilirubin in the skin, making it easier for the newborn's liver to process it. After 24 hours of phototherapy, a repeat bilirubin level was drawn, and it had dropped to 10 mg/dL, indicating the treatment was effective. The baby's skin color started to return to normal, and his irritability decreased. The CMP and CBC results also came back normal, indicating no liver dysfunction or hemolytic anemia. The baby continued to feed well and maintained regular bowel movements, which helped in the excretion of bilirubin.

These findings are encouraging, but the nursing team will continue to monitor the baby's bilirubin level and overall condition closely. The baby will remain under phototherapy until his bilirubin level drops further. The parents are educated about the importance of regular feeding and bowel movements in managing jaundice and are reassured that with continued treatment and monitoring, their baby's condition is expected to improve without any long-term complications.

Section 3

Change in Patient Status:

After another 24 hours, the newborn's bilirubin levels were rechecked, this time falling to a safer level of 6 mg/dL. The baby's skin color now appeared normal, and he was much less irritable than before. His feeding patterns remained consistent and he had regular bowel movements. His weight was stable, showing good signs of growth and development. A physical examination revealed no hepatosplenomegaly, a condition where both the liver and spleen swell beyond their normal size, which could have indicated a serious underlying condition causing the jaundice.

Response to Interventions:

Given these findings, the pediatrician decided to discontinue the phototherapy, as the bilirubin levels had decreased significantly and there were no other concerning symptoms. The nursing team continued to provide supportive care, maintaining the baby's hydration and nutrition, and encouraging the mother to maintain regular breastfeeding to further assist in the excretion of bilirubin. The parents were taught to look for any changes in the baby's skin or eye color, feeding habits, or level of alertness that might indicate a rise in bilirubin levels. They were also informed to bring the baby back for a follow-up visit in a week to ensure that the bilirubin levels remain normal. The baby was discharged in stable condition with instructions for home care and follow-up.

Section 4

Change in Patient Status:

A week after discharge, the newborn was brought in for the follow-up visit. The parents reported no changes in the baby's skin or eye color, feeding habits, or level of alertness during that week. The baby continued to show good signs of growth, having gained an additional pound in weight since discharge. However, the parents did note that the baby seemed to be slightly more irritable than usual, showing signs of discomfort especially during feeding.

New Diagnostic Results:

During the physical examination, the pediatrician noted mild abdominal distension. The baby's vital signs were normal with a heart rate of 145 beats per minute, respiratory rate of 35 breaths per minute, and a temperature of 98.6 degrees Fahrenheit. A repeat blood work was ordered to reassess the bilirubin levels. The results showed an increase in bilirubin levels to 8 mg/dL, indicating a mild resurgence of jaundice. Additionally, the complete blood count revealed a slightly elevated white blood cell count of 14,000 cells per cubic millimeter, which could be indicative of an infection.

Section 5

Initial Assessment Findings:

During the assessment, the nurse noticed that the baby's skin appeared slightly yellowish, a common sign of jaundice in newborns. The baby's sclera also had a faint yellow tint. On palpating the abdomen, the nurse observed that the baby showed signs of discomfort and the distension was still prominent. The mother reported that the baby's feeding had been normal but the baby seemed to have more gas than usual, often crying during feeds and passing stools that were greenish in color. The baby's diaper count was appropriate with five urinations and three bowel movements in a 24 hour period.

New Diagnostic Results:

Given the elevated bilirubin levels and the baby's symptoms, the pediatrician ordered a stool sample to check for any abnormalities that might indicate an underlying digestive issue. The results showed that the baby's stool was positive for reducing substances, indicating a possible intolerance to lactose. The pediatrician also ordered a sepsis workup due to the elevated WBC count, inclusive of blood and urine culture. The pediatrician advised the parents to keep the baby well hydrated and monitor for any changes in the baby's behavior or feeding habits.

This leads to considerations for alterations in the baby's diet to manage the possible lactose intolerance, while also waiting for the culture results to confirm or rule out any infection. The pediatrician's advice on hydration was crucial as dehydration can increase bilirubin levels and exacerbate the baby's jaundice. This scenario creates an opportunity for the parents to learn about newborn care and nutritional needs, especially regarding feeding practices for a baby with possible lactose intolerance.