help on baby

[OBstudent0321]

I am questioning now about my baby's priority diagnosis!! She has more data including: acrocyanosis (was born yesterday and still has!), irregular heart rate and rhythm...the dr. noted this as typical sinus arrhythmia and is considering doing chest x-ray and EKG), and has brusing on her labia majora. She is getting breastfed and seems to have no problems with that. Her head AND chest circumference are both 34 cm (head should be bigger..I'm wondering what problems relate to this); weight 3166 g and had good Apgar's (7 at 1 min, 8 at 5 min).

Do you have any nursing dx suggestions??? I am more confused about this one!!!

Thanks!!!

[Daytonite, BSN, RN]

Nursing diagnoses are always based on the patient's symptoms that they are displaying. You still need a nursing diagnosis reference to refer to in order to help you classify these properly:

• irregular heart rate and rhythm
  
• typical sinus arrhythmia - Decreased Cardiac Output
  
• breastfed - Effective Breastfeeding
  
• has bruising on her labia majora - Impaired Skin Integrity
  
• acrocyanosis - Impaired Skin Integrity
  
• head AND chest circumference are both 34 cm (head should be bigger - Risk for Delayed Development

Priority can be determined by Maslow's Hierarchy of Needs.

[OBstudent0321]

Thank you on your input! I actually used ineffective tissue perfusion as her priority dx. She did have a decrease of 6% of body weight today, but I realize that decrease is expected in the first week of life. However, she did have some jaundice today (in face & upper chest), but her total bili came back normal (10.6). She got dismissed today & didn't exhibit acrocyanosis or bruising today either. Do you think that tissue perfusion should have still been my priority today?? Maybe more breastfeeding to rid the body of the jaundice??