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BNUR 415 Clinical E-Logbook – Semester 1, AY 2023-2024
Specialty Area Rotation Report Form
Student Name: Shouq Alanzan
October 17, 2023
ID Number:
Date: NCTU:
Grade:
/4
Clinical Objectives:
At the end of ICN(NHDU) rotation I will be able to:
–
Identify Characteristics of a preterm baby.
–
Understand common problems of preterm baby.
–
Know Indications of phototherapy & Different types
–
Apply nursing interventions for a baby underphototherapy.
SITUATION:
Identifying Information:
Patient’s first name: Saad
Date of Admission: October 13, 2023
Age: 5d
Area: ICN(NHDU)
Code Status: full code
Allergy to food/medication: no known allergy.
Fall Risk: high risk
Infection Control status: standard precaution.
BACKGROUND:
Chief Complaints:
5 days old boy admitted to NHDU as a case of prematurity birth at GA 33+2 weeks and rule out sepsis,
neonatal jaundice(physiological)
Medical/Surgical History:
No medical hx.
No surgical hx.
Maternal history:
–
G3 T1 P1 A1 L2
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BNUR 415 Clinical E-Logbook – Semester 1, AY 2023-2024
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Blood group and Rh: A+
GBS: negative
HPV: negative
Medically and surgically free
Previous NVSD, term, no complication
Current pregnancy PROM 11/10/2023
Antenatal ultrasound findings: OB growth on 11/10/2023 was normal growth, AFI 8cm, normal doppler.
Medication during pregnancy: completed dexamethasone.
ASSESSMENT:
Vital Signs:
Temperature/route: 37.1C
Blood Pressure: 87/59mmHg.
Pulse: 124bpm
Respiratory Rate: 52bpm
SpO2 (when applicable): 97% Pain score/scale: 0 out 10 / CRIES
Physical Examination Findings:
• APGAR Score: (Best Care)
1st min: 9
5th min: 9
•
•
Cord contained 3 vessels. (Best Care)
Growth parameters:
Weight:46
Height:1.990
Head circumference:31
Chest circumference:28
Abdominal circumference:27
•
Head Assessment: Sutures are movable, Anterior Fontanel and Posterior Fontinales palpated. No signs of
bruising or bulging, both eyes symmetrical, pupils are equal round and reactive to light. Nose is symmetrical
to face, nares is patent, External ears canal present, no skin tags. neck inspections intact.
•
Chest: Round symmetrical shape, nipples and breast are symmetrical.
•
Respiratory: Equal bilateral breathing pattern, normal breathing rate 52 bpm, no abnormal breath sounds
heard.
•
CVS: Normal heart rate 124 bpm, normal heart sound S1, S2, no abnormal heart sounds are heard.
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BNUR 415 Clinical E-Logbook – Semester 1, AY 2023-2024
•
GI: slightly rounded, soft and normoactive bowel sounds. Umbilicus is dry.
•
Genitalia: normal preterm male genitalia, passing normal urine output, positive bowel motion, patent
anus.
•
CNS: Active, moving all limps with good ROM on upper and lower extremities, good muscle tone.
•
Skin: slightly yellowish skin color, warm, no signs of pressure ulcer.
•
Reflexes: weak Rooting and sucking reflexes, positive Moro reflex, positive grasp reflex.
Medications: patient received one medication
(best Care)
Medication
Dextrose 10%
in water
Dose / Route/ Frequency
250 ml IV continuous 9ml/hr.
Classification & Action
Side Effects
Sterile, nonpyrogenic, hypertonic Increase blood
solution – to prevent
glucose level,
hypoglycemia. (Louik, 2010)
phlebitis and
thrombosis in site of
injection, possible
hyperosmolar
syndrome. (Louik,
2020)(it should be
recent)
Laboratory Results:
(Best Care)
Investigation
Patient Value
Normal Value
Interpretation
Bili T
235.2 umol
~205 umol
hyperbilirubinemia
Glu R
3.2 mmol
2.2 ~ 3.3 mmol
Normal blood glucose level
WBC
9.35
5.1 ~ 20.5 * 10^9/L
Normal WBC level
Other Diagnostic Procedures, Specify:
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BNUR 415 Clinical E-Logbook – Semester 1, AY 2023-2024
No diagnostic procedures done yet, rather than daily labs.
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BNUR 415 Clinical E-Logbook – Semester 1, AY 2023-2024
RECOMMENDATION/PLAN
Treatment Plan:
As doctor ordered and Best Care the treatment plan is:
•
Admitted on NHDU
•
TFI 80ml/kg/day
•
Completed ampicillin for 48 hours.
•
To observe vital signs
•
Change the double phototherapy to Single phototherapy.
•
CBC daily
Nursing Care Plan: (Best Care, NANDA)
Nursing Diagnosis
Changed in skin color to yellowish related to
hyperbilirubinemia as evidenced by bilirubin T is
235.2 umol.
Actual Nursing Interventions
–
Risk for Aspiration related to impaired sucking/
swallowing reflexes secondary to prematurity
–
Monitor bilirubin levels.
Assess infant for skin color; note color
(yellowing) of skin or eyes.
Apply phototherapy as prescribed.
Assess skin and eyes every two hours during
phototherapy.
Monitor increased temperature/ fever.
Apply eye shield during phototherapy.
(Nursing Care Plan (NCP) for Neonatal
Jaundice | Hyperbilirubinemia, n.d.)
maintain good oral hygiene.
position infant in side- lying position or
supine.
Positioning the infant upright position
while feeding.
Burp the patient after feeding.
keep the head of the bed elevated if not
contraindicated. (Ralph & Taylor, 2010)
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BNUR 415 Clinical E-Logbook – Semester 1, AY 2023-2024
Risk for infection related to premature immune
system.
–
Obtain cultures as ordered.
Maintain aseptic technique during invasive
procedures.
Maintain hand washing and infection n.
control measures.
Monitor the newborn temperature or any
signs of infection. (Best Care)
Documentation: (As in Hospital Information System: BESTCARE, Nursing notes)
As in Best Care for October 17,2023:
7:00 Handed over for continuity of care, with two identification bands.
Received baby asleep under double phototherapy, on room air, and IV line on left hand.
7:30 environmental cleaning was done, emergency equipments are checked of availability
and functional; including ambue bag with correct size face mask connected with the oxygen
source, suction tube is connected to the wall with correct pressure.
8:00 physical assessment, body temperature, and skin assessment are done.
9:11 feeding given as prescribed with aspiration precaution and burped after.
9:45 cares done, kept clean and dry.
10:00 Doctor round and team. Case reviewed, ordered to change the phototherapy to single,
and confirmed.
10:45 cares done; vital signs taken. Passed stool and urine. Re positioning the saturation
probe.
11:30 mother came and ID band was checked and verified. Cuddled her baby and tried to
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BNUR 415 Clinical E-Logbook – Semester 1, AY 2023-2024
breastfeed, then asleep.
References:
➢ Best Care
➢ NANDA
➢ Louik, C. (2010). Risk factors for neonatal hyperglycemia associated with 10% dextrose infusion. Archives of
Pediatrics & Adolescent Medicine, 139(8), 783. https://doi.org/10.1001/archpedi.1985.02140100045025
➢ Nursing Care Plan (NCP) for Neonatal jaundice | Hyperbilirubinemia. (n.d.). [Video]. NURSING.com.
https://nursing.com/lesson/nursing-care-plan-for-hyperbilirubinemia-of-the-newborn-infant-jaundiceneonatal-hyperbilirubinemia#
➢ Ralph, S. S., & Taylor, C. M. (2010). Sparks and Taylor’s Pocket Guide to Nursing Diagnosis (1st ed.).
Lippincott Williams & Wilkins.
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BNUR 415 Clinical E-Logbook – Semester 2, AY 2023-2024
Specialty Area Rotation Report Form
Student Name:
ID Number:
NCTU:
Date:
Grade:
/5
Clinical Objectives:
SITUATION:
Identifying Information:
Patient’s first name: _________________________ Age: _______ Area: ___________________
Date of Admission: ___________________ Code Status: _____________ Fall Risk: _________
Allergy to food/medication: ______________________ Infection Control status: ___________
BACKGROUND:
Chief Complaints:
Medical/Surgical History:
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BNUR 415 Clinical E-Logbook – Semester 2, AY 2023-2024
ASSESSMENT:
Vital Signs:
Temperature/route: _________________ Pulse: ___________ Respiratory Rate: ____________
Blood Pressure: _________ SpO2 (when applicable): _____ Pain score/scale: _______________
Physical Examination Findings:
Medications:
Medication
Dose / Route/ Frequency
Classification & Action
Side Effects
Laboratory Results:
Investigation
Patient Value
Normal Value
Interpretation
Other Diagnostic Procedures, Specify:
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BNUR 415 Clinical E-Logbook – Semester 2, AY 2023-2024
RECOMMENDATION/PLAN
Treatment Plan:
Nursing Care Plan:
Nursing Diagnosis
Actual Nursing Interventions
Documentation: (As in Hospital Information System: BESTCARE, Nursing notes)
References:
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