faithful64 1,630 Views
Joined: Jul 4, '08;
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Your answers cleared up a lot for me. I will be sure to consider these factors more from now on when giving newborn care. I kind of understood about subnormal temps, but your explanations made it much more succinct.
Thank you! I really do appreciate it.
Thank you all for your replies. I learned so much from them, particularly those of Jolie, babyktcher and rn/writer. I was already sure I would not accept that order again out of fear of doing the wrong thing, but now that I understand why I can feel confident in that decision.
from Jolie : “The immune system of a newborn baby or young infant (even a healthy, full-term baby) is immature and can't be relied upon to act in the same way as the immune system of an older child or adult. Fever in any infant 6 months or younger must be evaluated medically. Also newborns and young babies are typically unable to "localize" their symptoms. A baby with a relatively minor infection such as a UTI or ear infection will present much the same way as an infant with a serious infection such as pneumonia, meningitis or sepsis. Their symptoms are vague and non-specific and the only way to determine a minor illness from a potentially life-threatening infection is to do a thorough work-up.
While the use of antibiotics is appropriately dropping in most patient populations, the newborn infant is one patient who may need antibiotics based upon a presumptive, rather than proven infection. While practices vary somewhat, in most cases, if there is a high index of suspicion, a septic work-up is done and a baby placed on broad spectrum antibiotics while awaiting the results of cultures. To do otherwise may allow an infection to progress to a dangerous point.
If culture results all come back negative, then antibiotics will be stopped. If they come back positive, they will be modified to medications that are specific to the bacteria identified.
As for fever, the baby in your care likely had an elevated temp due to his surroundings and activity prior to birth. If mom had a temp, baby was exposed to a "sauna" prior to delivery. Also the work of labor and delivery may result in some temp elevation of both mother and baby. It was important for you to be able to continue to monitor the baby's actual temp after delivery (without interfering factors such as Tylenol or bathing), both of which would likely lower his temperature regardless of infectious process, and skew your information.
Finally, what may be even more dangerous in a newborn than a fever (which helps to fight infection) is a sub-normal temperature. Babies who are too sick to maintain their own body temperature will have a sub-normal temp. This is a danger sign that an infant is very ill..”
I really didn’t have a good understanding of any of this until your excellent explanation. Thank you so much for taking the time to write it! I just learned a lot. I’m also left wondering why the infant received a bath in the nursery an hour after I took her down there.
from babyktcher " All of this happening in the recovery phase? I would think to wait to do such drastic measures. This woman has just pushed out a baby, worked hard at it, and the baby has been thru a rough phase itself. Why not give it an hour or so for everyone to normalize and then evaluate for some pathology."
This is the same rational I heard from the experienced L&D nurses, that the infant may have been transitional and could normalize, so give it a little more time. What alarmed me about the mother's temp was that it was consistently in the 97s throughout labor and eventually rose to 102.0 before starting the come down.
"Do midwives generally order for newborns in your facility and not the pediatrician?"
In this particular instance the CNM was the provider for both mom and baby. This incident came to the attention of the head of all departments involved and is being reviewed I believe for the purpose of no longer having this CNM have pediatric privileges as she has made this same order in the past. I was unaware of the issue until after I accepted the first order and in retrospect I am really glad that I called the nursery for clarification. A ped took over care after I took the baby to the nursery to have blood drawn. She has been on antibiotics since yesterday morning.
from rn/writer “Do you know the GBS status of the mom? Was she experiencing any other s/s?”
The mom was GBS negative with no s/s other than fever.
I do have another question. When you guys mention low temps in a newborn, how low is low? It is wonderful to be able to come here and ask questions without being made to feel stupid for not knowing the answers
Thank you for sharing your experience, very inspiring. I'm sure your pt will never forget you.
I became an RN last summer and was hired onto a Family Birthing unit. I have done postpartum since August and began L & D training last month. Doing PP I have had a few baby's go south and so I am very vigilant with them. Two nights ago during a NSVD recovery, I noticed both mom and baby temps rising every 15 minutes. This was a midwife delivery and there were many variable and some late decels the last four hours of labor during which my preceptor and I continually monitored, turned the pt, bolused, had her on 10 L O2 via face mask etc, as well as frequent contact with the midwife. The baby had yellow mec on it's back at birth.
An RN from our special care nursery caught the baby and was with her the first 20 minutes or so. I received an order for ibuprofen when mom's temp was 100.9. When I checked baby hers was 100.7, the nursery nurse was still at our desk so she offered to do a rectal temp, which was 100.9. I called the midwife again about baby and was given an order for Tylenol. She couldn't give me a dose so I called down to the nursery and asked what the normal dose is for a newborn.
At this point the nurse who answered the phone read me the riot act that I had just accepted an unsafe order and needed to call back and refuse it and demand a septic workup. I called back and (politely) mentioned that there was concern the child needed a workup and she ordered a CBC, CRP and blood culture. The nurse who caught the baby had been discussing the hx with the one who answered the phone. When I took baby to them to have the blood drawn I was given a stern talking to about never,ever, EVER giving Tylenol for newborn fever as it can mask the signs of infection. I was unaware of this and so were several of my coworkers, and some of them are quite seasoned OB nurses.
So... my question is, is this always true? Is it ever appropriate to give a newborn with a temp tylenol? I want to the best I can by my patients.
Thanks for taking the time to read this.
I graduated in June but started applying for work in February, had lots of interviews in March and signed my contract on April 28. I interviewed at all the local hospitals and ended up landing my dream job in OB. I worked this past year as an LPN at a hospice house. I found that the response to my having worked as an LPN the last year was very favorable in all of my interviews. Even though OB and hospice are totally different, I wouldn't trade the experience for anything. It's been very valuable to me as far building my confidence and practicing clinical skills...and I enjoyed the work. Also, a big plus for me was that my DON at the hospice was friends with the DON at the OB unit where I was hired, so she was able to call her and ask what she thought of me. I did not know this ahead of time, but at least where I live, the world of nursing can be very small and having connections sure helps.
I will say that the process of looking for an RN job while in school was very stressful to me, because I felt like everyone in my class was getting offers before I did, which wasn't true, but boy did it feel that way. BUT, I'm so glad I did it. It was a great feeling knowing I would be starting soon after school. Some of my friends who waited last year until they had their RN license still didn't have jobs 6 months later.
So, for my 2 cents, if you want to get your license and work as an LPN this next year, go for it! You never know, your LPN job may lead you straight into your RN job. And apply early, and be persistent. Good luck!
Wooty-woot-woot!!!!!!!!! It worked for me too! Just found our I passed! No more studying, no more stressing,
I feel like a million pounds were just lifted from my shoulders.
Good luck to all who are still waiting...the "trick" rocks!
I am hoping that by Monday I too will be confirming that the trick works. I never heard of it before yesterday, but came to allnurses for moral support after a brutal NCLEX-RN yesterday morning. Every other question was on meds, 8 SATA, etc, shut off at 75 and I literally thought I would vomit when I walked out of there. The PN was much easier for me. Nothing anyone said made me feel any better and then I read about the trick and tried it and got the pop-up! At least I was able to sleep last night. Hoping this means I passed, I'll post again when I find out. Thanks to whoever discovered the trick and posted it.
I accept your apology Daytonite, and don't mean to be thin-skinned. I appreciate the time you took to critique my plan. I do hate that about the in internet, when you can't see and hear the other person it can be hard to "read" their meaning.
I just wrote a lengthier reply, which I wasn't finished with, but I hit something and it disappeared, so I think it may be showing up here eventually. Thanks again.
While I know you have decades of experience and are the local NANDA guru, when your reply comes off as a personal attack it's hard to take any of the great points you may have. Yes, I researched pancreatitis, alcoholism and liver disease ... and I've been using Ackley's Nursing Diagnosis Handbook, and my Med-Surg book the whole time.
If you were holding his free fluid, it sounds like he definitely has a problem with fluid volume excess. The hyponatremia, hypertension, and hemodilution (lowered HH) fit with this. I asked if there were any signs of impaired perfusion as with a significantly lowered H&H, there may not enough hemoglobin to meet the body's O2 needs.
Now I get it, that totally makes sense. I appreciate your explanation.
Thank you for your reply. His hyponatremia was not yet bad enough to be causing issues. But, during my shift his intake was 700ml and his output was 2150, I did not see any evidence of third spacing but with his I & Os being that far out of whack the fluid volume deficit could be a problem. And frankly, I am not experienced with third spacing. The doc was holding his free water because of the hyponatremia.
I guess I also don't understand tissue perfusion. he did have a distended abdomen and his BP was 168/92, but the BP was already a problem for him. I can't find anything else to fit with this.
I will go with your suggestion about the skin, I'm sure you are right.
I am just about done with my care plan, but need help with prioritizing diagnoses. My pt is a 45 yo male with severe pancreatitis. Has been in the hospital for over a month. he was admitted after a long holiday ETOH binge. His labs are crazy: cholesterol is 653, triglycerides 4783, amylase 1009, glucose 250, albumin 2.4, Hct 23.2, Hgb 8.1 and he is making giant platelets, not to mention he is hyponatrmeic.
He is in acute pain, is recieving feeding through a j-tube, has lost 33 pounds since admit (but is still quite overweight). Can't move himself in bed and has a 20 cmx 15 cm excoriation on his buttocks. he was able to walk 30 steps with PT and a nurse but was completely exhausted afterwards.
there is a lot more detail I could go into, but my diagnoses are as follows:
1. Acute pain r/t inflammation and distention of pancreas
states pain 7/10
rx morphine sulfate
CT results, cystic lesions throughout pancreas
lab values as above
2. Imbalanced nutrition less than body requirements r/t NPO staus and increased metabolic demands
J tube feeding Jevity
weight loss 33 lbs
large stage 2 pressure ulcer, buttocks
3. Activity intolerance r/t pain, weakness, prolonged hospitalization
unable to turn self in bed
2 person assist bed to chair
2 person assist ambluate 30 steps leaves pt exhausted
4. Impaired skin integrity r/t imbalanced nutrition, prolonged bedrest
5. powerlessness r/t physical condition prolonged hospitalization
I've skipped the details for the sake of time on the last two, but have lots of AEB.
Can I combine 3 and 4? and if not, which comes first, impaired skin itegrity or activity intolerance?
Thanks for your help,
Sorry to hear you are feeling overwhelmed. Trust me it does get easier. I have been a palliative care nurse now for 12 years and I love every minute of it. Palliative care is not easy. It takes time, and the thing about palliative care is that it can be very unpredictable. My suggestion is to not try so hard. Step back take a deep breath and relax. Just think what is the worst that can happen, and can you deal with that. Probally so!!! I find this to be the most rewarding of all nursing. Think of it as helping someone to make a transition from this life to the next.
Thanks for that. I believe you hit the nail on the head...I am trying too hard! I think I was expecting myself to know how to do everything as soon as this orientation is over. But I can tell I'm really going to love this once I'm a bit more confident. I'm already crazy about just about every patient I've had so far and feel honored to be there with them while they make their journey.
Thanks Leslie, I appreciate the advice. I will make sure she is aware of what I don't know yet! How do you deal with a patient who needs one on one when your other patients have needs?
I just got my license a little while back and I'm still in school full time for RN. I was thrilled when I was offered the job at the in patient hospice house that I did my clinical rotation in this summer. I have wanted to work in hospice care since long before I started school.
After six days of orientation I will be starting on my own, with 5 patients. This is a 10 patient unit and there will always be an RN on the other side as well as a NAC working the whole unit.
When I agreed that I was ready, I didn't quite understand that she meant and now I'm not so sure. Last night I had my first swing shift (4th day on the floor orienting) and it got pretty intense when an older gentlemen kept wanting to escape. I gave him his prn haldol, but it didn't seem to help at all, he just got more agitated, when he got his second dose an hour later he eventually settled down, but not without a few tears and some belligerence. Because I was still orienting with another nurse, she was able to stay with him for almost 2 hours while I attended to the other patients. But I still had to ask her questions about what I was doing and I wondered what I would have done if I were alone? When I'm been on day shift there have been social workers, chaplains and volunteers there too, so there is always an extra hand if you need one, but not in the evening.
I'm also still learning the paper work and protocols there and have not experienced a death. I have voiced my concerns to my supervisor, but she told me that she wouldn't have asked me if she didn't think I was ready, I just needed to get out there and do it.
I am comfortable with patient and family care, I love hospice and find most of the staff very supportive. I still have two more evenings orienting before I'm on my own, but I'm losing sleep over this. Any advice
would be great.
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