SKINNY Reasoning by Hanna Steckler

Relevant Data from Report:

kxczwf9h9p — 2024-09-26 12:40:04 UTC

-17 years old

-Rh - factor

Clinical Significance:

kxczwf9h9p — 2024-09-26 12:45:47 UTC

-complications could occur due to young age

-she is at risk for socioeconomic issues related to work, possibly affecting finishing school

-receive rhogam within 72 hours after birth to prevent her blood from making antibodies that attack Rh positive blood cells

Clinical Significance:

kxczwf9h9p — 2024-09-26 12:51:03 UTC

-disruption of education

-mental health and wellbeing such as postpartum depression

-how much is a while to the mother to breastfeed or how long does she plan on breastfeeding

Relevant VS Data:

kxczwf9h9p — 2024-09-26 12:54:18 UTC

-everything is WDL

Clinical Significance:

kxczwf9h9p — 2024-09-26 12:54:47 UTC

-vital signs appears WDL

Relevant Data of Social History

alexiamackey95 — 2024-09-26 13:02:25 UTC

When considering the social history of a 17-year old. An essential factor is the environment, and family dynamics.

The young mother is living with her mom, she is experiencing partner abandonment.

Social support could aid in her ability to care for the newborn.

It would be important to follow up with the safety of her household, although her mom is stating she is able to care for her daughter as well as her newborn granddaughter.

Patient Care Begins

alexiamackey95 — 2024-09-26 13:07:13 UTC

Relevant Vital Sign Data:

Pain level is important, We would want to assess her ability to understand pain levels.

Assessing the Fundus integrity, making sure it is firm and midline.

-Interventions: Fundus massage frequently

Lochia Assessment: Ensuring that bleeding is coming to a halt at proper timing, as well as assessing, if any foul odor, any blood clots.

Vital Signs Relevant Data:

alexiamackey95 — 2024-09-26 13:14:12 UTC

BABY VITAL SIGNS

97 is slightly below the normal range (97.7-99.5) it indicated mild hypothermia or low body temp.

Due to

Environmental factors (A cold room, or not adequately wrapped in clothing or blankets)

Inadequate skin-to-skin contact

(Educate her the importance of proper skin to skin attachment, swaddling)

Interventions: Recheck the temp in a short period to see if it improves with warming.

Collaborative Care (Newborn Orders)

alexiamackey95 — 2024-09-26 13:19:31 UTC

Rationale VS: Monitoring well-being fetus. Monitoring to make sure it stays in expected range

Skin to Skin: Bonding/Attachment, regulating temperature.

Bathe after 6-8 hours: Promoted temp regulation. Gives time for the neonates vitals to stabilize after birth

Breastfeeding: Encourage the baby is receiving enough calories. Provides energy and nutrients for the first weeks of life.

Similac: Ensure the baby is appropriate weight