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Pediatric Case Study

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Diagnosis: Single Live Birth via Cesarean Section
Definition: An infant showing one of the three evidences of life (breathing, heart action, movements of a voluntary muscle) after complete birth. In some countries a live birth is considered not to have occurred if the infant dies during the 24 hours following delivery. Which of these two definitions is used has considerable effect on various vital statistics concerned with the viability of the fetus at time of delivery. Textbook Symptoms:

* Breathing
* Heart action
* Movements of voluntary muscle.
Patient Symptoms:
* Breathing
* Heart action
* Movements of voluntary muscle.

Diagnostic Tests/Labs:
* PKU- Results pending
* Test for phenylketonuria
* A congenital autosomal recessive disease marked by failure to metabolize phenylalanine to tyrosine. * It results in severe neurological deficits in infancy if it is unrecognized or left untreated. PKU is present in about 3.5 in 10,000 newborns in the U.S. In this disease, phenylalanine and its by-products accumulate in the body, esp. in the nervous system, where they cause severe mental retardation (IQ test results often below 40), seizure disorders, tremors, gait disturbances, coordination deficits, and psychotic or autistic behavior. Eczema and an abnormal skin odor also are characteristic. The consequences of PKU can be prevented if it is recognized in the first weeks of life and a phenylalanine-restricted (very low protein) diet is maintained throughout infancy, childhood, and young adulthood. * Biliscan- 3.7 mg/dL

* Within normal range
* 1-12 mg/dL
* Used To evaluate liver function.

Treatments: No treatments ordered
Nursing Care
0730: Quiet, lying on bed between mother’s legs with father at bed side. 0830: Alert. Pulse- 128 bpm. Temp-98.1⁰ A. Respirations-34. Sa02-99%. Skin is warm, pink, and dry with turgor and capillary refill less than 3 seconds. Bilateral PERRL 3mm. Heart sounds normal and regular. Respirations even and unlabored. All lobes in lungs clear anteriorly, posteriorly, and bilaterally. Abdomen soft and non-distended, with bowel sounds present in all four quadrants. Radial and pedal pulses 2+. Hand grips and leg strength strong and equal. Shows no signs of pain. Laying in crib at mother’s bedside.

I went in to introduce myself to the family. The mother was lying in bed with the patient and the father was at the bedside. Both were very quiet and distant. I helped the mother feed her because the mother said her breast were too sore. I bottle fed her then swaddled her tightly and laid her in her crib. About an hour later, I came back and did my assessment on her. Her father was gone, and her mother was half asleep so I then changed he diaper and cleaned her up with a sponge bath. Before leaving I swaddled her and put her back in her crib. She went fast to sleep. A couple hours later, her mother asked for her to be taken out of the room so she could sleep. I brought her to the nurse’s desk and rocked her. Everyone came up and cooed over her. She got a ton of attention, and people just couldn’t get enough of her. She started to get fussy so I gave her another bottle, and she quieted down again. I rocked her some more then she fell asleep in my arms. Another hour passed and I changed her diaper and laid her back down in her crib. Another half hour passed and her mother was ready for her again. After I came back from lunch, it was time for her to be discharged. I helped her mother clean her up and dress her in a cute outfit. I helped put her in her carseat and carried her down to their car when it was time to leave.

Drugs: No drugs ordered

Psychological Effects: Family is supportive and caring. She will adjust well with family.
Development (Reflexes):
* Rooting Reflex- causes the infant’s head to turn toward warm objects that touch the cheek. Present. * Sucking Reflex- causes the infant to suck on objects placed in the mouth. Present. * Protrusion (Extrusion) Reflex- causes food placed on the front portion of the tongue to be pushed out of the mouth. Present. * Step (Dance) Reflex- causes the infant to make stepping or dancing movements with the fee; occurs when the infant is held upright in the air; disappears at about 6 weeks of age. Present. * Grasp Reflex (Palmer and Plantar)- causes the infant to clench or grasp the hand or foot; occurs when pressure is applied at the base of the fingers or toes; disappears at about 3 months of age in the hand (palmer) and about 9 to 12 months in the foot (plantar). Present.

* Moro Reflex- Causes the infant to extend arms outward with thumb and forefinger in a c-shape and the other fingers extended; occurs in response to sudden movement; disappears by 6 months of age; assessment is made by symmetry and response time. Present. * Startle Reflex- causes the infant to extend arms outward with hands clenched; occurs in response to loud noise; disappears by six months of age. Present. * Tonic Neck Reflex- causes the infant to attain the fencing position with the arm on the side the infant is facing extended and the other arm flexed toward the head; occurs when the infant is laid back; may not be present for a few weeks and disappears at about 7 months. Not present.

Prognosis: Good; she presents no health problems at this time.
Rehabilitation: Patient teaching on infant care given to family at discharge. They will follow.


Patient’s Chart
Taber’s Cyclopedic Medical Dictionary- F.A. Davis
Textbook of Basic Nursing- Caroline Bunker Rosdahl and Mary T. Kowalski
Mosby’s Manual of Diagnostic and Laboratory Tests- Kathleen Deska Pagana and Timothy J. Pagana

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