SBAR and Medical diagnosis help

[elilop]

Can someone help me with a SBAR for this case study? do you know some possible medical diagnosis for this patient?

You are the nurse taking care of a 36 hour old 36 week gestational age male. Birth weight 3.2 kg. The mother is a 24 year old G1 P1. The mother had good prenatal care. Mother's blood type is O+, VDRL NR, GBS +, Rubella Immune. This pregnancy was complicated by gestational diabetes, diet controlled. Mother admitted in labor and progressed to precipitous lady partsl delivery within 30 minutes of admission. She received no medications prior to delivery.

Infant has been stable since birth, blood sugars stable. He is breastfeeding every 2-3 hours. He has voided and passed stool. Upon your initial exam you note the below:

Temperature 96.2o F, HR 176, RR 86, anterior fontanel open soft, eyes/ears grossly normal, mild nasal flaring, respirations even with mild retraction, breath sounds clear, intermittent grunting, Gr 3/6 murmur, active precordium, abdomen soft, flat with active bowel sounds, pulses 2 +/= in upper extremities and 1+/= in lower extremities, capillary refill 4 seconds.

[DayDreamin ER CRNP]

What do YOU think the SBAR should include? Why are you having to come up with a medical dx in the first place? That is really beyond our scope of practice.

Why don't you post what you have so far on the SBAR and we can help you from there.

[elilop]

My teacher is a bit crazy and asked us to come up with some possible medical Dx.

This is what I got for the SBAR: let me know what you think...

Situation: The patient _____ in room _____ is a 36 hour old male newborn experiencing a new onset respiratory distress.

Background: The patient is a 3.2 Kg baby born at 36 weeks of pregnancy after a precipitous delivery. The mom is a gravida 1, para 1 who had very good prenatal care. She suffered of gestational diabetes during pregnancy which was controlled with diet, all her lab values were WNL but she tested positive for GBS.

Assessment: The baby’s blood sugars are stable and he is breastfeeding every 2-3 hours. He also voided and passed stool. Temperature 96.2o F, HR 176, RR 86, mild nasal flaring, respirations even with mild retraction, intermittent grunting, Gr 3/6 murmur, active precordium, pulses 2 +/= in upper extremities and 1+/= in lower extremities, capillary refill 4 seconds.

Recommendations: My recommendations would be to take the baby’s oxygen saturation, have an arterial access ready for frequent ABGs monitoring, take a blood culture and CBC to rule out possible GBS of the neonate, and we also will need an echocardiogram in order to rule out CHD. It will be also a good idea to start the baby with oxygen.

[BittyBabyGrower, MSN, RN]

You have your medical diagnosis right in there....think about it. CHD, GBS.