INTRODUCTION. This is a case study for baby Joyce Chitini, born to Mrs. Joyce Chitini, a para 3. Mrs.

Chitini delivered at bwaila hospital on the 26th of October, 200 , and !ot dischar!ed on the 2"th of October 200 . On the 2 th, her baby developed #aundice, which, pro!ressed !radually till it was !enerali$ed. %he brou!ht the neonate to the hospital on the 2& th October. Jaundice is the yellow discoloration of the s'in and con#unctivae due to the presence of bile pi!(ent in the blood. )n new borns it is usually caused by the brea'down of red blood cells which releases a yellow substance called bilirubin. *ilirubin is processed by the baby+s body before it is e,creted throu!h baby+s urine and stools -http.//nursin!crib.co(0. This process is nor(al after birth and it usually does not re1uire treat(ent. 2owever, in so(e cases, (ore severe or pronounced #aundice is a si!n that the baby+s body can not process bilirubin 1uic'ly enou!h and in such cases phototherapy is needed to speed up the process of brea'in! down bilirubin. This neonate was cared for four days, after which she was dischar!ed. This write up then discusses and critici$es the type of care that this neonate was !iven throu!hout hospitali$ation and it includes )t includes the assess(ents done, the care provided, the dischar!e plan and analysis of the situation. The first part e,plains the detailed account of the day3to3day care of this neonate while the last part is the criti1ue of the care that was !iven. PERSONAL HISTORY. Mrs. J.Chitini is 30 years old and resides at 4rea 25, near the apostolic church at Miss. 6ose Chilo(o+s plot. %he is a house wife and (arried to a sales(an at *eco international %he is Chewa by tribe and so too is her husband. Mrs. Chitini belon!s to 6o(an Catholic Church and she went to school up to for( four but she never attended any tertiary education thereafter because she did not do well in her Malawi school certificate of education e,a(ination. PREVIOUS OBSTERTRICS HISTORY. This is the third child for Mrs. Chitini (eanin! that she has !one throu!h labour three ti(es as well. 4ll the pre!nancies were sin!letons and they were all spontaneous verte, deliveries. The first child was born at a hospital in 2003, while the second born was born at a traditional birth attendant in 2007 and this child was born here at bwaila hospital. They are all !irls. %he e,plained that she had antepartu( bleedin! durin! the first pre!nancy, but had no any other proble(s durin! the subse1uent pre!nancies. %e said all her children cried i((ediately after birth and were avera!e si$ed. Mrs. Chitini did not e,perience any proble(s related to lactation and breast feedin! as she e,plained that her breast were producin! enou!h (il'. PRESENT OBSTETRIC HISTORY. Mrs. Chitini e,plained that she had her last (enses in 8ece(ber, 200" but she could not re(e(ber the e,act date and this (eant that, her esti(ated date of delivery in %epte(ber 200 . Mrs. Chitini drained li1uor for two days before the actual delivery, and apart fro( this, she never e,perienced any abnor(al sy(pto(s li'e bleedin! or abnor(al headache.

%he also e,plained that she attended antenatal care three ti(es at bwaila durin! this pre!nancy as follows. Date of visit '(.)*.)+ )*.)+.)+ )2.)3.)3 Gestation Fun a! "ei#"t ', '* 2) 2' 2( 2* $%esentation Ce$"a!iCe$"a!iCe$"a!i&ei#"t *../0#s *+0#s .)0#s B!oo $%essu%e 1 1 1 Feta! "ea%t Positive Positive $ositive

4ENSTUAL AND GYNAECOLOGICAL HISTORY. Mrs. Chitini attained (enarche at the a!e of 93 years and since then her (enstrual cycle has been re!ular32 days cycle. %he (enstruates for 7 days and the nature of her (enstrual flow is (oderate. %he said she does not e,perience any dys(enorrhoea. 4dditionally she has never had an abortion or ectopic pre!nancy. CONTRACEPTIVE HISTORY. Mrs. Chitini displayed ade1uate 'nowled!e in fa(ily plannin! by e,plainin! that she 'nows various (ethods li'e pills, in#ection, condo(s and bilateral tubal li!ation. %he ad(itted not havin! adopted any type of fa(ily plannin! (ethod because her church does not allow fa(ily plannin!. PSYCHOLOGICAL HISTORY Mrs. Chitini e,plained that this was a planned pre!nancy, both the client and her spouse have accepted and, are ready for the baby. SE5UAL HISTORY. Mrs. Chitini said nothin! chan!ed on her se,ual response durin! pre!nancy even ri!ht now, however, she said in her culture a wo(an is not supposed to have se, with her husband soon after delivery until the baby is si, (onths old. 4EDICAL HISTORY. The client denied any history of tuberculosis, asth(a diabetes renal disease, heart disease, epilepsy, hypertension and (ental illness. SURGICAL HISTORY. Mrs. Chitini denied havin! under!one any type of sur!ery includin! uterine sur!ery, vesical va!inal fistula repair or 3rd de!ree repair: however she ad(itted havin! sustained a s(all tear durin! this delivery which was repaired by a (idwife.

FA4ILY HISTORY. %he said she does not have any history of so(e of the hereditary conditions li'e tuberculosis, heart disease diabetes (ellitus epilepsy and (ental illness, but her !rand (other is hypertensive. %he also denied history of twinnin!. SOCIAL HISTORY. Mrs. Chitini is the first and only wife to Mr. Chitini. 2er husband went to school up to for( four after which he pursued a certificate in (ar'etin!. ;one of the( s(o'es nor ta'es alcoholic bevera!e. NUTRITIONAL HISTORY. Mrs. Chitini said she has ade1uate 'nowled!e of si, food !roups and she said she is able to afford the food sources without any proble(s fro( her !arden. %he e,plained that even the ti(e she has been in hospital her relatives and friends are brin!in! her food every (eal, <or e,a(ple, a day before she ca(e to the hospital she had tea with (il' and dou!hnuts in the (ornin!, nsi(a with boiled n'hwani and e!!s for lunch and durin! supper she said she had nsi(a, beans and cabba!e plus banana for supper. This 25 hour dietary recall shows that this client is able to afford all the si, food !roups, On food preparation, she li'es stewed food and salads rather than boiled ve!etables. )n her culture she said she is not aware if there are any dietary restrictions related to pre!nancy and lactation.

=2>%)C4? @A4M);4T)O;. Beneral appearance. 4 healthy loo'in! (other, well 'e(pt in body and clothin! well nourished with no si!nificant abnor(al feature. %he was happy at the ti(e of e,a(ination. Cital si!ns. Te(perature. 3".9 de!rees celsius. *lood pressure. 926/&0 ((2! 6espirations. 96 breaths per (inute. =ulse rate. beats per (inute. Dei!ht. 6" 'ilo!ra(s. HEAD1TO1TOE E5A4INATION. Hea . well distributed hair, no dandruff, well co(bed hair. Fa-e. sy((etrical features, no acne seen. Ea%s. no enlar!ed ly(ph nodes palpable. Nose. no nasal stuffiness of dischar!e. 4out". pin' ton!ue and (ucous (e(branes, no oral thrush, no Eaposi+s lesion seen. Ne-0. no ly(phadenopathy, full ran!e of (otion. U$$e% e6t%e7ities. war( s'in, palpable brachial and wrist pulses, full ran!e of (otion, no ede(a of the fin!ers, !ood capillary refill.

C"est an !un#s. sy((etrical chest no retraction or bul!in! of intercostals spaces durin! inspiration and e,piration, sy((etrical e,pansion. ?ow pitched resonance of (oderate intensity. B%easts. clean nipples, supple, sy((etric in si$e and contour, dar'er pi!(entation of nipple and areola present, superficial veins pro(inent, (il' present. Lo8e% e6t%e7ities. popliteal artery palpable stron! and re!ular, no ede(a nor varicosities seen. ABDO4INAL E5A4INATION. Ins$e-tion. loose s'in on the abdo(en seen. ;o visible scar, striae !arviduru( and linea ni!ra pro(inent. Pa!$ation. abdo(en non tender, liver and spleen non palpable. Fterus palpable #ust above the sy(physis pubis. Va#ina! ins$e-tion. vulva clean, with (ild, pale pin' lochia seen on the sanitary pad, no sores seen, no warts or varicose veins. Dell done sur!ical sutures seen on the perineu(, ti!htly sewn and intact. 8i!ital va!inal e,a(ination was not done. Conclusion on the physical e,a(ination, nothin! si!nificant was detected. PHYSICAL E5A4INATION OF THE NEONATE. GENERAL APPEARANCE. The baby was active and alert in a well fle,ed position, with a yellow s'in colour for the whole body includin! e,tre(ities. %oles of the feet and pal(s were also yellow. %'in te,ture was s(ooth and soft with no dry peelin! of the hands and feet as in post (ature baby. There were no s'in pustules or rash. The baby did not have any con!enital obvious abnor(ality. The Bestational a!e assess(ent showed that that baby was about 3& wee's. Cital si!ns were. Te(perature. 36.2 de!rees celsius =ulse rate. 922 beats per (inute 6espirations. 52 breaths per (inute 2er wei!ht was 3200'!s. HEAD 1TO 1TOE E5A4INATION. 2@48. The head was sy((etrical to the body. 2ead circu(ference was 37c(.There was no caput or (ouldin!, the fontanels and sutures were nor(al si$e. *oth the anterior and posterior fontanels were palpable, neither were they sun'en nor bul!in!. @>@%. There was (oderate whitish dischar!e on both eyes. *oth eyelids were swollen.

There pupil was clear not su!!estive of opacities. The sclera was sli!htly red possibly due to infla((ation caused by the neonatal ophthal(ic but it was not su!!estive of trau(a. There was no subcon#uctiva hea(orrha!e. The nose. was patent without dischar!e or polyps. There was no nasal flarin! The ears. the pina was well developed, the ears were patent there was no dischar!e. The upper corner of the ears was in line with the outer corner of the eyes. The (outh. There were no witch teeth, no oral thrush. There was no cleft lip plate or cleft hard palate. 6ootin! and suc'lin! refle,es were present. T2@ ;@CE There were no lu(ps, swellin! and webbin! F==@6 @AT6@M)T)@% The ar(s were sy((etrical: there was no fracture of clavicle or bone of the ar(s. There were no e,tra di!its. =al(er clenses were present.Braspin! and (oro refle,es were present. T2@ C2@%T The chest had nor(al barrel shape.There was sy((etrical breathin! (ove(ents.The respiration was nor(al with 5 breaths per (inute without chest indrawin,subcoastal retraction. T2@ 4*8OM@; The u(bilical cord was ti!htly secured and not bleedin!.There was no e,o(phalus.The liver and spleen was not palpable T2@ ?OD@6 ?)M*% The le!s were sy((etrical.There were no e,tra di!its.There were no fractures.The Otolan+s si!n was ne!ative for con!enital hip dislocation.The feet had no talipes and webbin! between di!its.Braspin! reflect was present Dal'in! refle, was present T2@ B@;)T4?)4 The anus was patent but baby had not yet passed (econeu( but passed urine. The urethra openin! was present at centre of !lans penis and the testes were 8escended. T2@ *4CE The spine was even not su!!estive of (enin!ocele or %pina *ifida Crown to heal len!th was 3 c(. .

ANALYSIS OF THE ANTENATAL CARE )n tryin! to (ini(i$e (aternal neonatal (ortality, the (inistry of health and population launched a national safe (otherhood initiative with four pillars of services one of which is focused antenatal care. <ocused antenatal care is the care where the nu(ber of visits to attend antenatal care is reduced but co(pensates the client by increasin! the client3provider ti(e, -Obstetrics ?ife s'ills trainin! (anual, 20000. 4s per reco((endation by the safe (otherhood initiative, every wo(an is scheduled for four antenatal visits, first at the initial -boo'in! visit0, second visit after si, wee's if the pre!nancy is less than 2 wee's !estation or four wee's if pre!nancy is (ore than 2 wee's, third and fourth visits are scheduled four wee's apart. -Obstetrics ?ife s'ills trainin! (anual, 20000. 2owever, Mrs. J.C attended only three visits, first one at 25 wee's, then at 30 wee's and finally at 37 wee's. 8urin! these visits she received care as follows. inter(ittent preventive treat(ent twice and ferrous sulphate supply for a (onth three ti(es. /. La9o%ato%: e6a7inations; <ra$er et al -20060 e(phasi$es that 'nowled!e of he(o!lobin level, blood !roup and any syste(ic infections in a pre!nant wo(an help in plannin! appropriate care durin! pre!nancy, labor and delivery hence preventin! co(plications. a0 He7o#!o9in !eve!. this test (easures the a(ount of he(o!lobin, the o,y!en carryin! factor, and red pi!(ent of the blood. 4s a reco((endation by safe (otherhood, every pre!nant wo(an is supposed to be tested for ane(ia at boo'in! and at 36 wee's. This is done to rule out anae(ia in pre!nancy which is one of the leadin! causes of (aternal (ortality in Malawi. 4dditionally, it brin!s with it a lot of co(plications li'e pre(ature labour, intrauterine !rowth retardation as well as intrauterine deaths and (any (ore. Obstetrics life s'ill trainin! (anual -20000 defines ane(ia as a he(o!lobin level of less than 90 !ra(es per deciliter which is a result of deficiency in the 1uality or 1uantity of red blood cells .Mrs. J.C+s he(o!lobin level at boo'in! was 90.2 !ra((es per deciliter which is the borderline of nor(ality and (ild anae(ia. This was never repeated at the third visit or any other visit. b0 B!oo #%ou$. this is done to deter(ine the (other+s blood !roup in case of need for transfusion, but also to e,clude 6hesus ne!ativity which pre disposes to abortion and fetal re#ection especially if the father or fetus is 6hesus positive and vice versa. Mrs. J.Cs !roup was * positive, which (eant that shat she belon!s to blood !roup * type with a positive 6hesus factor. c0 VDRL. this is translated to Cenereal 8isease 6esearch ?aboratory test and it is perfor(ed for syphilis. 2owever, not all positive results indicate active syphilis. @arly testin! will allow a wo(an to be treated in order to prevent infection of the fetus. 8urin! the whole antenatal period, Mrs. J.C. was never tested for C86?. This had ne!ative i(plications on the (other as well as of fetus because not

'nowin! the results (eans deprivin! both the (other and the fetus of treat(ent, thus e,posin! the( to abortion, (alfor(ation and disfi!ure(ent. d0 HIV. this is done after pretest counselin! to start treat(ent or ad(inister prophylactic treat(ent of niverapine which is beneficial in reducin! vertical trans(ission to the fetus. e0 U%ine fo% a!9u7in. this was done to e,clude albu(in in urine which is an indication of abnor(alities such as pre!nancy induced hypertension or urinary tract infections. This was done at boo'in! visit and it was found to be ne!ative. f0 %tool (icroscopy was not done. !0 Feta! $%esentation ana!:sis. throu!hout the 3 visits, Mrs. ;dholo+s fetal presentation has been cephalic. 4s e,plained in the obstetrics life s'ills trainin! (anual -20000 the fetal position which is often associated with appropriate pro!ress of labour and delivery is the verte, presentation, hence breech, transverse or obli1ue presentations durin! intrapartu( is a ris' associated with a very hi!h perinatal (ortality if delivery is done by people with little trainin! or e,perience. '<. P%o$":!a6es. The prevention or treat(ent of (aternal ane(ia should be part of focused antenatal care -obstetrics life s'ills trainin! (anual 20000. Dith re!ards to the level of he(o!lobin for Mrs. J.C which was relatively low, ferrous sulphate was supplied to her every ti(e she attended antenatal care. %he was also !iven fansidar 3 tablets which she too' under direct observation at the clinic once for prevention of (alaria as an inter(ittent prophyla,is treat(ent. <ocused antenatal care reco((ends that (alaria prophylactic treat(ent be !iven to every antenatal (other three ti(es durin! the antenatal period, after 96 wee's !estation -or after 1uic'enin! has ta'en place0 and before 36 wee's !estation -obstetrics life s'ills trainin! (anual 20000. This is done to every pre!nant wo(an as per !uidelines by the safe (otherhood because (alaria resistance is reduced durin! pre!nancy and inter(ittent prophyla,is treat(ent is used to avoid fre1uent attac's of (alaria which predisposes the (other to hae(olysis of red blood cells and anae(ia which (ay lead to pre(ature labour or abortion. %ince Mrs. J.C received fansidar only once in the whole antenatal period, it (eans that she was not fully protected fro( (alaria and she was at hi!h ris' for developin! (alaria at any ti(e. This also put the fetus at ris'. 2er late attendance to antenatal care could have also contributed to this proble(, because she started antenatal care at 25 wee's !estation the ti(e she was e,pected to have received her second dose of fansidar. 4dditionally she was also !iven an insecticide treated net for the sa(e purpose of (alaria prevention at the first visit.

%afe (otherhood also e(phasi$es the need for a co(plete dosa!e of tetanus to,oid vaccine in order to prevent neonatal deaths due to tetanus, usin! the cheapest easy to access (ode, thus vaccination. Mrs. J.C finished her schedule durin! the second pre!nancy and she was appraised for this. 30. Routine 7i 8ife%: o9se%vations. h0 Olds -20000 e,plains that it is i(portant to note the pattern of wei!ht !ain durin! pre!nancy in order to evaluate the need for nutrition counselin!, obtain infor(ation on eatin! habits, coo'in! practices, need for food supple(ents, pica and other food habits. 2owever for this to be done effectively there is need to note the initial wei!ht to establish baseline for wei!ht !ain throu!hout pre!nancy. Throu!hout the antenatal period, Mrs. J.C+s wei!ht was (onitored and it was ran!in! between 6".9 '!s to "0 '!s with an avera!e of 6 .3'!s. 2er initial wei!ht !ain is not 'nown but on avera!e she was !ainin! 0.9&'!s per wee'. 4ccordin! to Myles -9&& 0, nor(al wei!ht !ain durin! the second tri(ester, is 0.7 'ilo!ra(s per wee', which (eans that this client+s wei!ht at this ti(e was lower than e,pected. This is very worriso(e especially in pre!nancy because it could be a warnin! that so(ethin! is wron! so(ewhere. ?ac' of or reduced weiht !ain can be due to e,cessively low carbohydrate and fat inta'e which decreases (aternal wei!ht and fetal !rowth that can result to intrauterine !rowth retardation and/ or intrauterine death in e,tre(e cases. )n conclusion, Mrs. J.C. did not receive ade1uate care durin! her antenatal period because due to so(e reasons, she did not under!o so(e i(portant laboratory e,a(inations li'e C86?, blood !roupin! and stool (icroscopy. 4dditionally, so(e vital observations li'e blood pressure chec' was not done throu!hout her care antenatally. %ellers -20030 e(phasi$es the i(portance of chec'in! blood pressure antenatally while followin! and analy$in! its pattern in order to e,clude and identify pre!nancy induced hypertension, hence early intervention. Throu!hout the three visits, Mrs. J.C+s blood pressure was not (onitored. SU44ARY OF LABOUR AND DELIVERY Mrs. J.C laboured for 22 hours, which was not acco(panied by draina!e of li1uor. %he only had one va!inal e,a(ination and fetal and (aternal response to labour was also (onitored once3durin! ad(ission. %he was seen a!ain in her second sta!e when the head of the fetus was at the vulva. %he delivered a live full ter( fe(ale infant wei!hin! 3200! by spontaneous verte, delivery. 4p!ar score was /90 then 90/90. Two hours later she was dischar!ed to low ris' post natal ward. 8urin! the third and fourth sta!e nothin! abnor(al was indicated. =lacenta was re(oved throu!h CCT and it was recorded to be co(plete.

ANALYSIS OF LABOUR AND DELIVERY =erri and ?owder(il' -20060 e,plains that labour is considered nor(al when the wo(an is at or near ter(, no co(plications e,ist, a sin!le fetus presents by verte,, and labour is co(pleted within 9 hours in (ultiparas or up to 20 hours in nulliparas. )n this case Mrs. J.C+s labour, which too' al(ost 22 hours, could be considered prolon!ed. =rolon!ed labour predisposes both the (other and fetus to ascendin! intrauterine infection durin! and after delivery -Myles, 20020. This is (ainly due to the fact that the cervical os re(ains and 'eeps on openin! throu!hout labour. This could be because she was (issed out and was not followed up thereafter, because soon after ad(ission, she was sent for a(bulation, and to await established labour in the waitin! roo(, where no staff !oes to chec' on the patients. This (ay also be reason fetal and (aternal (onitorin! never too' place thereafter until she was in second sta!e of labour.

=6O*?@M% )8@;T<)@8 <O6 *4*> =otential for brain da(a!e related to inability to con#u!ate bilirubin. 2i!h ris' for infections related to prolon!ed labour. 2i!h ris' for altered nutrition less than body re1uire(ents related to feedin! difficulties 2i!h ris' for respiratory distress syndro(e related to pre(aturity 2i!h ris' for #aundice related to pre(aturity and infections 2i!h ris' for hypother(ia related to pre(aturity =6O*?@M% )8@;T<)@8 <O6 MOT2@6 9.4ctual proble( of an,iety related to baby+s condition 2.4ltered baby and parent bondin! related to intensive nursery care 3.2i!h ris' for infection related to prolon!ed labour. 5.2i!h ris' for breastfeedin! proble(s related to nutrition deficit. 7. 4ctual proble( of 'nowled!e deficit on si, food !roups related to lac' of infor(ation 6. 4ctual proble( of 'nowled!e deficit of %e,uality durin! puerperiu( related to cultural taboos ". 4ctual proble( of poor health see'in! behaviour related to late attendance for antenatal care. . lac' of fa(ily plannin! i(ple(entation related to reli!ious belief. . ;on co(pliance on focused antenatal visits &. =otential for intrauterine infection or se,ually trans(itted infection

M)8D)<@6> C46@ =?4; 4ID&IF&ER Y DIAGNOSIS 4ctual proble( of eye infection related to prenatal and intrapartu( infection of (other GOAL INTERVENTION RATIONALE S The baby prevent ;urse baby To will of in isolation spread de(onstrate infection to no si!ns of Clean eyes other babies infections with nor(al To re(ove eye within 7 saline usin! dischar!e and days of clear clean cotton help (ana!e(en infection swabs t 4d(inister Tetracycline To treat by 'illin! oint(ent causative hourly (icroor!anis( Dash hands s before and To prevent after eye cross infection care To rule out Chec' con!enital (other for syphilis for C86? pro(pt (ana!e(ent as neonatal optha(ia (ay be as a result of se,ually trans(itted disease passed on fro( (other. EVALUATIO N Chec' condition of eyes once everyday to asses for i(prove(ent

4ID&IFER Y DIAGNOSIS 4ctual proble( of an,iety of (other related to baby+s condition (anifested by (other as'in! 1uestions about baby

GOAL Mrs.<.* should de(onstrate understandin! of baby+s condition and e,hibit no si!ns of an,iety throu!hout hospitali$atio n

INTERVENTION S @stablish a !ood nurse Gclient relationship @,plain to (other about baby+s condition,pr o!nosis and every intervention 4llow (other to as' 1uestions )nvolve the (other in the care of the baby @,plain the routines and protocols of the ward e.! nursin! baby in isolation roo(, handwashin ! before

RATIONAL E 3To pro(ote open co((unicatio n and verbali$ation of concerns 3To allay an,iety and pro(ote her cooperation 3To pro(ote verbali$ation of her feelin!s for pro(pt (ana!e(ent 3To raise her self confidence on the care of the baby and allay an,iety 3To allay an,iety and pro(ote her cooperation in the care

EVALUATIO N

touchin! baby,re(ovi n! shoes when enterin! the nursery

4ID&IFER Y DIAGNOSIS 4ltered (other3baby bondin! related to baby+s condition

GOAL The (other and baby should (aintain bondin! throu!hout hospitali$atio n

INTERVENTIO S @,plain to (other about baby+s condition and the need to be nursed in isolation nursery @ncoura! e and assist with e,clusive breastfeed in! @ncoura! e the (other to cudle baby,tal' to hi( when breastfeed in! or carin! for her

RATIONALE 3To pro(ote understandin!,alla y her an,iety and !ain cooperation.

EVALUATIO N

3provides chance for (other to carry her baby for (other and baby to e,plore each other feelin! and pro(otes closeness 3@ncoura!es bondin!

4ID&IFER Y DIAGNOSIS =otential proble( of altered nutrition less than body re1uire(ent related to feedin! difficulties

GOAL To (aintain the re1uired nutritional needs of the baby throu!hout hospitilisatio n

INTERVENTION S 34ssess baby+s ability to suc'le and swallow 3Teach (other and assist with proper breastfeedin! attach(ent and postionin! 3)f unable to suc'le fro( breast discontinue and insert naso!astric tube for feedin! for feedin! e,pressed breast(il' 3=rovide baby with 90H !lucose in water if (other unable to e,press enou!h breast(il' 3=rovide feeds calculated based on daily wei!ht 34dvise the (other to ta'e 6 food

RATIONAL E 3<or plannin! of appropriate feedin! (easures 3To pro(ote e,clusive breastfeedin! to (eet baby+s body re1uire(ent 3To provide baby with enou!h e,clusive breast(il' to (eet body re1uire(ents 3To provide baby with ade1uate !lucose to (eet (etabolis( re1uire(ents 3To (eet nutritional re1uire(ents for the baby 3To pro(ote production of

EVALUATIO N Dei!hin! baby on altenate days to assess wei!ht !ain

!roups with (ore enou!h proteins and (ore breast(il' to fluids atleast 3litres (eet baby+s in day re1uire(ents

4ID&IFE RY DIAGNOSI S 2i!h ris' for infections related to pre(aturity

GOAL

INTERVENTION S 3<ollow infection prevention (easures.(other and health wor'ers to wash hands before and after contact with baby,(other to re(ove shoes when enterin! the nursery 38o u(bilical cord care once daily 3 @ncoure!e and assist with e,clusivebreastfeed in!

RATIONA LE 3To prevent spread of infection to the baby.

EVALUATION

The baby should not develop infections throu!hout hospitilisati on

Chec' vital si!ns 2 hourly to detect si!ns of infection e.! hyperther(ia or hypother(ia,tachycar dia

3To prevent entry of (icroor!anis ( throu!h the cord which is a raw wound 3<or baby to ac1uire passive i((unity throu!h colostru(s i.e )! 4,)! C and additional pha!ocytic cells which 3Ta'e blood sa(ple helps to fi!ht for full blood count infections 3To chec' si!ns of infection e.!

increased white cell count for pro(pt (ana!e(ent

4ID&IFER Y DIAGNOSIS 2i!h ris' for respiratory distress syndro(e related to pre(aturity

GOAL The baby will not develop co(plication s of pre(aturity throu!hout hospitilisatio n

INTERVENTIONS 3Chec' vital si!n I hourly for one hourly increasin! fre1uency when condition is stable

RATIONAL E

EVALUATIO N

3<or early identification of si!ns of respiratory distress syndro(e for pro(pt (ana!e(ent 3Chec' si!n of 3<or proper respiratory distress and pro(pt syndro(e i.e (ana!e(ent cyanosis,!runtin!,nas al flarin!,subcoastal retractions 3=rovide o,y!en 3To help (eet therapy 2litres/(inute ade1uate if baby develops the !aseous condition e,chan!e to prevent co(plications 3To prevent 3;urse the baby under hypother(ia rediant war(er with which can te(perature well cause re!ulated respiratory and(onitored distress syndro(e

NURSING PROGRESS RECORD /+TH AUGUST='))+ &.304M S 6eceived the baby fro( labour ward nurse who reported that they had brou!ht the baby for ad(ission in nursery baby was born with e,cessive eye dischar!e. O; On head to toe assess(ent of baby there was no si!nificant findin!s e,cept that the baby had swollen eyelids and purulent eye dischar!eand it was pre(ature. Cital si!ns were te(perature 36.6de!rees celcius,heartrate 990/(inute,respiration 5 /(inute A . 4ctual proble( of eye infection related to (aternal perinatal and intrapartu( )nfection. 4ctual proble( of pre(aturity related to pre(ature labour P; 4s per care plan To ta'e co(prehensive antenatal,intrapartu( history after ad(ission of baby. I; )ntroduced (yself to the (other and infor(ed her that ) had identified her baby as (y as (y casestudy.)nfor(ed the (other about the baby+s condition and that he would be ad(itted in ;ursery isolation roo( for proper (ana!e(ent.%he was also i(for(ed the plan of care ,e,pectations fro( her such as infection prevention (easures and 2hourly feedin! of the baby.The (other de(onistrated understandin! of the e,planations. &.504M *aby was properly covered and put under a radiant war(er with te(perature set at 26de!rees celcius to provide war(th and prevent hypother(ia. Dashed hands with soap and runnin! water The baby was placed on its bac' ,eyes cleaned and Tetracycline eye oint(ent applied 90.00a( )t was ti(e for feedin! the,observed the (other breastfeedin! and she was havin! breastfeedin! proble(s the baby could not suc'le and (other was producin! less (il'. 4dvised the (other to e,press and feed with a cup.told to feed baby with 90 (l per feed accordin! baby+s wei!ht and she was shown how (uch that was usin! the feedin! cup

4dvised to altenate cup feedin! with breastfeedin! to sti(ulate baby+s suc'lin! refle, and (il' production as it sti(ulates release of o,ytocin The (other was also advised to eat ade1uately and (eals to co(prise 6 food !roups Dith plenty of fluids. 99.27 4.M Chec'ed the baby the linen was wet with urine.=rovided baby with clean and dry linen 4nd covered baby well to prevent heat loss. Cital si!ns were chec'ed te(perature 3".2de!rees celcius,heartrate 992beats/(inute, 6espirations 5" breaths per (inute. 92 =.M Mother ca(e for breastfeedin! she was assisted to e,press breast(il' in a cup but %he only e,pressed 5(ls.%he verbali$ed that she was hun!ry as she had not eaten since Mornin!. Told the (other that this could have contribute to poor (il' prodiction %he was counseled on the i(portance of ta'in! ade1uate food to pro(ote (il' =roduction.The plan was to continue (onitorin! feedin! to ensure baby+s !et enou!h to (eet body re1uire(ent. 2=.M % . Mother ca(e for breastfeedin!,she reported that she was still havin! difficulities *reastfeedin! she had tried to put baby to breast but baby not suc'lin!. O. Observed the (other e,pressin! (il' she only e,pressed about 7 (ls.The supply was )nade1uate. 4 .=otntial proble( of nutrional deficit related to feedin! proble(s = . 4s per care plan Ta'e co(prehensive history of (other for antenatal,labour and delivery ) .4ssisted the (other with baby+s attach(ent and positionin! to breast and *aby (ana!ed to suc'le . 2istory was ta'en and records reviewed where it was noted that antenatal (other did ;ot have blood for C86? and that she had pron!ed pre(ature rupture of (e(branes =lan was to have C86? done and have clinician to review (other the followin! day for to assess and treat infection if present.The (other was infor(ed about her condition and plan of care and she accepted. 5=.M 4ssesed baby+s vital si!ns Te(perature 3".5 de!rees celcius,heartrate990beat/(inute, 6espirations 56beats/(inute.There were nor(al *aby had so(e yellowish eye dischar!e in eyes.@ye care was done and baby left clean. 5.77 =.M 4ssed the baby there was no dischar!e in eyes.The linen was dry and clean the baby co(fortable.)nfor(ed (other about baby+s condition and infor(ed her ) was 'noc'in! off.6e(inded her about 2hourly feedin! and adherences to )nfection prevention (easures with e(phasis on hand washin! before breastfeedin! the baby.

Bave handover to ni!ht duty nurses to continue (onitorin! baby+ condtition throu!hout The ni!ht and 'noc'ed off. 84> 2 .9& 4FBF%T,200 .00 4.M S . 6eceived hand over fro( the ni!ht duty nurses who reported that the baby+s eye )nfection was worsenin!.The baby was producin! e,cessive eye dischar!e which was Breenish in colour.The baby was suspected to have con!enital syphilis. The nurses covered the baby on antibiotics .*en$ylpenicilln 907,000J)F 92 hourly <or 7 days and Benta(ycin 90(! once a day for 7 days.%he also had Tetracycline @ye oint(ent in the (ornin!. Mother reported the baby was feedin! well and the a(ount of (il' she was e,pressed 2ad increased.%he reported to have feed baby about 6 ti(es durin! the ni!ht. O . *aby assessed vital si!ns Te(perature 3".3celcius,heartrate 90 beat/(inute, 6espirations 5 breaths /(inute.The eyes were clean without any dischar!e. A . 4ctual proble( of infection. P .4s per care plan To continue (onitorin! baby for infection,feedin! proble(s to prevent co(plications Of pre(aturity. Chec' (other for C86? and treat her if positive I . 8u(p dustin! done,baby+s linen chan!ed and baby provided with clean and dry linen 4nd left sleepin! in a co(fortable environ(ent. Calculated the a(ount of (il' to be !iven per feed and it was 97(l showed the Mother this 1uantity usin! the feedin! cup. .304.M Cord care was done,the u(bilical cord was cleaned with nor(al saline,de(inistrated To the (other on how to do it the cord was and left dry to prevent a !ood (ediu( for (ultiplication of (icroor!anis(s. 4lso advised the (other to watch for si!ns of #aundice in the baby such yellow stainin! of s'in and eyes as preter( babies are at hi!h ris' of developin! #aundice. 90.004.M Observed the (other breastfeedin! the baby assisted with positionin! and 4ttach(ent to breast baby was able to suc'le a little.%uple(ented e,pressed (il' with 90 (l of e,pressed breast(il'. 90.20 4.M 6e(inded the (other that she was to be chec'ed for C86? this day because The baby was de(onstratin! si!ns neonatal Opthal(ia caused by se,ually trans(ited infection which he (i!ht have ac1uired fro( her. Chec'ed with the sister in char!e on this (atter who infor(ed (e that the test is not bein! done at *waila as there are no rea!ents and advised to ta'e the (other to %e,ually Trans(itted disease clinic for proper (ana!e(ent. 99.074.M Dent with the (other to the %T) clinic where upon assess(ent she was %y(pto(atically treated for Bonorhea.%he was !iven Benta(ycin 250(! i((ediate dose once and @rythro(ycin 700(! hourly for 7 days and was as'ed to brin! her husband for treat(ent

Counseled the (other on dru! co(pliance and need to brin! partner for treat(ent to 4void reinfection.%he reported to infor( the husband when he co(es for visitin! so he Could !et treated ri!ht at this hospital. 92=.M Chec'ed baby vital si!ns which were nor(al te(perature was 3".5de!rees Celcius, heartrate 990 beats/(inute and respiration 70 breaths/(inute Mother feed baby with 97 (l e,pressed breast (il' and then put baby to breast and was able to suc'le and swallow. 2.00=.M 4ssessed the baby and found that the eyes were still swollen, there was (oderate purulent dischar!e. 2and washin! was done, @ye care done and the afternoon dose of Tetracycline eye oint(ent applied. 3.90 =.M The baby was reviewed by the 8octor who ordered the baby to (aintain the treat(ent he was receivin! until 7 days. 5.57=.M The baby was assessed the vital si!ns were nor(al Te(perature 3".3 de!rees celcius, heartrate 907beats/(inute, respiration 5 breaths/(inute. The (other was infor(ed on pro!nosis of the baby and encoura!ed her to continue breastfeedin! and hy!iene to (aintain the condition. 6e(inded her to feed baby 2hourly at ni!ht encoura!ed (other to curdle and chat with bay when feedin! to pro(ote bondin!. 2anded over the baby to ni!ht duty nurses to continue (onitorin! baby+s condition over the ni!ht and ) 'noc'ed off. 2% DAY; ') AUGUST= '))+ ".30 =.M S. ;i!ht duty staff reported that the baby had hypother(ia and they added e,tra linen to Eeep baby war(. The eyes were i(provin! e,cretin! less dischar!e .The baby had already received the (ornin! dose of antibiotics and eye oint(ent. Mother reported that baby was able to suc'le fro( the breast and was feedin! well. O. Cital si!ns were Te(perature 37.7 de!rees celcius, heartrate 990beats per (inute, respirations 72breaths per (inute. The eyes were clear without dischar!e and the eye lids were sli!htly swollen as swellin! was subsidin! . The baby+s linen was wet and soiled with (econeu(. A. 4ltered ther(ore!ulation hypother(ia, related to pre(aturely secondary to e,posure to Cold environ(ent (anifested by te(perature of 37.7 de!rees Celsius. P. To increase te(perature of radiant war(er to 30de!rees Celsius and (onitor hourly. Eeep baby in dry environ(ent to 'eep hi( war( =rovide baby with e,tra linen =ro(ote ade1uate feedin! of baby 20(l per feed 2 hourly accordin! to baby+s wei!ht =ost pone interventions that e,poses baby to cold e.!. wei!hin! and cord care until Te(perature is stable. 6echec' te(perature after 9 hour to evaluate effectiveness of interventions.

".5& 4.M I . The baby was wiped off (econeu( with a cloth wetted with war( water then its coat was cleaned and baby provided with e,tra clean and dry linen. Te(perature of radiant war(er was increased to 30 de!rees Celsius. To infor( (other of baby+s condition when she co(es for feedin!, discoura!e Fnnecessary e,posure and (onitor feedin! to ensure baby is !ettin! enou!h to (eet (etabolic re1uire(ents. To rechec' te(perature after 9 hour at .5& 4.M .5& 4.M Te(perature chec'ed it was 36. de!rees celcius: plan was to continue chec'in! hourly 4nd decrease fre1uency when te(perature stabili$es. 90.00 4.M The (other co(e for breastfeedin! and was infor(ed of the baby+s condition. %he was 4lso the a(ount of (il' to !ive baby per feed 20(l/per feed. *aby was !iven 20(l of e,pressed (il' and put on breast was able to suc'le. 6e(inded the (other to infor( the husband about need to be treated for %T) when he co(es visitin!. %he reported that the husband would co(e at ?unch brea' and she was !oin! to infor( hi(. 4s'ed her to tell her husband to (eet (e for counselin! on need for treat(ent. 92 =.M Te(perature was chec'ed it was 3".5 de!rees celcius.The te(perature of radiant war(er was reduced to 26 de!rees Celsius to prevent overheatin! the baby. 92.20 =.M The (other ca(e for breastfeedin! and baby breastfeed well without proble(s. The (other reported that the husband was around and she had infor(ed hi( about the treat(ent and he accepted. Counseled the couple to!ether and arran!ed for the husband to receive treat(ent at *waila %T) clinic after lunch brea'. 2=.M Chec'ed te(perature which was 3"." de!rees Celsius. The baby was wei!hed and his wei!ht was 2000!.The baby had lost 900! fro( the birth wei!ht this is nor(al physiolo!ical wei!ht loss which is e,pected for neonates to lose 90H of birth wei!ht within 90 days afterbirth and then start !ainin!. @ye care was done usin! aseptic techni1ue and Tetracycline eye oint(ent applied. Cord care was also done usin! nor(al saline. The cord was not bleedin! ,dryin! well and no si!ns of infection observed 2.30=.M Mother ca(e for breastfeedin! and she reported that the husband had also received treat(ent as per plan.Co(fir(ed by chec'in! in her health passport where this was docu(ented.

)nfor(ed the (other that the baby+s condition was i(provin! and if this continued she was !oin! to be dischar!ed in 2 days after the baby had finished antibiotic treat(ent )nfor(ed the (other that the followin! day was !oin! to be last day for the case study this was to !radually ter(inate nurse3client relationship. The baby was breastfeed without any proble(s. 5.=.M *aby assessed there eyes were i(provin! there was no dischar!e seen swellin! was subsidin!.Cital si!ns were te(perature 3".7 de!rees celcius,heartrate 90"beats/(inute,repirations 5 breaths/(inute.;o abnor(al findin!s detected. =lan was to continue (ana!e(ent as per plan. 5.92=( Mother ca(e for breastfeedin! and baby feed without any proble(s.The (other was counseled on <a(ily plannin! and puerperal se,uality as part of dischar!e plan and she de(onistrrated understandin! of the lessons by as'in! 1uestions and answerin! appropriately. 5.77=.M Te(perature was chec'ed it was 3" de!rees celcius.Told the (other to cover baby well and ensure he is dry all the ti(e to prevent hypother(ia. Bave hand over to ni!ht duty nurses and 'noc'ed off. ,t" DAY;'/ AUGUST='))+ .00 4.M S .Mother reported that baby was fine spent the ni!ht well. Das able to breastfeed and feed " ti(es durin! the ni!ht. The ni!ht duty nurses reported that the baby was i(provin!, was havin! less eye 8ischar!e and (ornin! te(perature was 36. de!rees Celsius O. *aby was active and alert, vital si!ns te(perature 36.& de!rees celcius, heartrate 992beats/(inute and respirations 56 breaths /(inute. ;o eye dischar!e observed and the eyelid were not swollen sli!ht erythe(atous.The treat(ent chart indicated that baby had already received (ornin! dose of antibiotics and eye oint(ent. A. *aby was i(provin! P. To continue nursin! care as per plan )(ple(ent dischar!e care plan Ter(inate nurse3client relationship .90=.M I. 8u(p dustin! done. *aby+s coat cleaned and linen chan!ed 90.904.M Mother beast feed baby and baby was able to suc'le without proble(s. Cord care was done usin! nor(al saline in the presence of (other the (other was 4dvised (other to continue doin! cord care at ho(e after dischar!e. 2.00=.M

Chec'ed vital si!ns te(perature 3"de!rees celcius, heartrate 990beats/(inute and 6espirations. *aby was breastfeed without any proble(s. The (other was counseled on !eneral care of the baby at ho(e and follow up care includin! follow up visits at the hospital. The (other was also infor(ed to have the baby i((uni$ed at follow up visit since baby could not be i((uni$ed while in hospital because his wei!ht was less than 2000!ra(s.4ccordin! to *waila procols pre(ature babies !et i((uni$ations when they are 2000!ra(s and above 2.30=.M @ye care was done and Tetracycline eye oint(ent. 5.30=.M Bave hand over to ni!ht duty nurses. Ter(inated relationship with (other.

%FMM46> O< T2@ C4%@ %TF8> ) feel ) !ave co(prehensive care to this baby and it was also (other centered did a co(prehensive assess(ent and analysis of the situation in order to provide appropriate and priority care. This baby was dia!nosed with opthal(ia neonaturu( and also had pre(aturity was able to identify factors durin! antenantal, labour and delivery period which could have contributed to these conditions. ) feel the cause for the Opthal(ia neonaturu( was (aternal undia!nosed and untreated antenatal infections .These infections could also be the contributin! factor for preter( labour.This is because Mrs <.* did not have co(prehensive history ta'e and laboratory investi!ation done durin! antenatal visit. <or instance she was not chec'ed for C86? to detect %yphilis and urinalysis for urinary tract infection as it is re1uired. This is reflects that the (other did not received 1uality antenatal care as re1uired in focused antenatal care. The baby+s condition is also associated with factors durin! labour and delivery as 8uloc' et al su!!est that events durin! labour and delivery influences the outco(e the neonate.Mrs <.* had preter( labour and pre(ature rupture of (e(brane and these also increases ris' of neonatal infections. This neotate was born pre(aturely at 33 wee's !estation and was at ris' of co(plications This baby received co(prehensive care as he did not develop co(plications of infections and pre(aturity. ) feel ) provided 1uality and (other centered care because ) was involved the (other in the care of the baby, encoura!ed bondin! and ) also facilitated for the (other and husband to !et treated for their infection. DISCHARGE CRITERIA The followin! were the standards which were used to assess fitness of the (other and the baby for dischar!e ho(e.

T2@ MOT2@6 Dell established lactation and ability to correctly position and attach the baby to breast. =hysically and psycholo!ically healthy and stable (other. 4bility to provide !ood care and safety to baby. 4bility to 'eep the neonate war(. 4bility to identify dan!er si!ns in the baby. *4*> %table vital si!ns within nor(al ran!e.36.733".2 de!rees Celcius,neonatal heartrate .9203 960/(inute and respirations .30360 breaths/(inute. *aby able to suc'le the breast well. ;o si!ns of infections. *aby able to pass urine and stools *aby active and all refle,es present *aby pin' not cyanosed or #aundiced 8ry u(bilical cord without i(fla(ation or any other si!n of infection. *aby received *CB and =olio Caccine. HEALTH EDUCATION AND COUNSELLING E5CLUSIVE BREASTFEEDING AND BREASTCARE The (other was tau!ht the i(portance of feedin! the baby breast(il' only until the a!e 6 (onths and introduce supple(entary feedin! after that. %he was told the advanta!es of e,clusive breastfeedin!. %he was re(inded to always wash hand before breastfeedin! to avoid spreadin! infection to baby. %he was also re(inded o breast positionin! and attach(ent to prevent breastfeedin! co(plications. %he was tau!ht to breastfeed the breast alternatively to prevent breast en!or!e(ent. Mrs <.* was also tau!ht to clean the breast with piece of cloth and clean water to 'eep it clean. NUTRITION COUNSELLING Mrs. <.* was tau!ht the i(portance of eatin! 6 food !roups to help in develop(ent of the body for successful lactation. %he was told that a !ood 6 food !roup diet should co(prise of carbohydrates, proteins, fats, oil, ve!etables and fruits. %he was advised to ta'e iron rich food to such as !reen leafy ve!etables e.!. bonon!we ;'hwani, liver and dry fish as these help in production of he(o!lobin and vit c rich food li'e citrus fruits because it aids absorption of iron. This was to increase her 2b and prevent ane(ia as she had lost so(e blood durin! delivery. %he was also advised to ta'e enou!h fluids at least 3litres in 25 hours as this helps in the production of (il'. SE5UALITY Mrs. <.* was discoura!ed on the taboo of abstinence up to 6 (onths postnaltally since this pro(otes unfaithfulness of the partner which increases the ris' of ac1uirin! se,ually trans(itted infections includin! 2)C

%he was counseled that it was safe to resu(e se, 6 wee's postnatal because by this ti(e the reproductive syste( returns to its prepre!nant state as lon! the wo(an is co(fortable and lochia had stopped. FA4ILY PLANNING Mrs. <.* was advised to start fa(ily plannin! 6 wee's after the baby is born because by this ti(e the reproductive syste( returns to its prepre!nant state and ovulation resu(es and she could !et pre!nant if she resu(es se, at this ti(e. %he was counseled to consider voluntary sur!ical contraception as she had under !one 5 deliveries as it is ris' for a wo(an to !ive (ore than five deliveries. CARE OF THE BABY %he was advised to ta'e !ood care of this baby to avoid neonatal or under five death as it occurred with the other 2 children. %he was advised to attend under five clinics up to the ti(e child is 7 years so that the child should !et all i((uni$ations and have the wei!ht (onitored for early detection of proble(s and pro(pt (ana!e(ent and the (other to !et )@C for health pro(otion. %he was also re(inded to 'eep the baby war( at all ti(es as he was at ris' of developin! hypother(ia due to pre(aturity. The (other was re(inded on cord care and i(portance of (aintainin! hy!iene to prevent the baby fro( developin! infections since the baby had underdeveloped i((une syste(. DANGER SIGNS @ducated the (other on the dan!er si!ns to watch the child for at ho(e which included. fever,#aundice,s'in pustules, eye dischar!e, convulsions and pus,redness on the u(bilical cord. %he was advised to brin! the baby to the hospital i((ediately if these sy(pto(s occur.

REFERENCES *ennet, 6. K *rown, ?.E -20060 Myles Te,tboo' of Midwifery3The 4frican @dition -95th edition0 @dinbur!, Churchhill ?ivin!stone 8ulloc', ?. 2 K Cinten, 4.% -9&&20 Martenal3;ewborn ;ursin! -9st @dition0 J.* ?ippincot .=hiladephia Mc@wan,8 K Ja(es,4 @lsevier.Churchill,?ivin!stone -20070 Obsterics in focus -9st @dition0

%weet, *.6 -20020 Mayes+s Midwifery -93th @dition0 ?ondon.*aillere Tindal M.O.2 ,-20090 <ocused 4ntenatal care M.O.2, -20020 safe (otherhood Manual

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