Discharge Nursing Case Study

814 Words 4 Pages
Five-day-old male accompanied by his mother and his father. Parents are the primary historians and they are deemed reliable.
Chief Complaint: First check up after discharge from the hospital.
History of Present Illness: This is a 5-day-old male presenting to the office for first checkup following discharge from the hospital 3 days ago. Parents report that baby is breastfed every 2-3 hours. Mom reports that baby is latching with no difficulties, feeding last about 20 to 45 minutes. During the hospital stay the baby was eating and sleeping. At home parents report increased fussiness and crying during last 48h.
Past Medical History: Patient was born at term to a G1P1 mother via spontaneous vaginal delivery. This pregnancy was complicated
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Mom is not able to state how much milk he is ingesting due to breastfeeding.
Habits: He woke up every 2-3h to feed at the hospital. Since he is home he has been showing increased fussiness and crying during last 48h. Mom has been feeding him every 2h. No exposure to tobacco at home.
Development: Suckling tongue movements, extension- retraction of tongue, up and down jaw movement, momentary head control when held sitting, startles to loud sound, undifferentiated but strong cry, quiets in response to voice.
Immunization: none
Family History: Mom reports H/O GERD, dad has no PMH.
Social History: Parents live in a single family home, no other family members, no pets. There is no sick contact at home. He does not go to daycare yet.
Review of Systems (SUBJECTIVE):
General: 5-day-old male appears well-groomed with reports of increased fussiness and crying.
Skin: (-) rash, (-) dryness, (-) suspicious lesions, (-) itching, (-) pigment changes, (-) texture changes, (-) unusual nail/ hair growth
HEENT: (-) head trauma, (-) eye discharge, (-) conjunctivitis, (-) ear discharge, (-) nasal discharge, (-) mouth ulcers, (-) tonsillar exudate, (-) anterior cervical lymphadenopathy, (-) tenderness, (+) spitting up after
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Plan:
• Advised mom to use a breast pump to assess how much milk she is able to produce. At this point child lost 15% of birth weight since discharge from the hospital. Mom may need to add a formula feeding to meet child’s nutritional needs. “The infant may lose up to 5% to 8% of birth weight but should regain it within 10 to 14 days. Weight gain after initial loss averages 0.5to 1 oz per day” (Burns et. al., 2015, p. 60). The child was discharged from the hospital weighing 3.27 kg and presents today to the office weighing 2.75kg. He needs to drink between 2-3oz of breastmilk or formula at each feeding between 3-4h.
• Discussed that no immunization will be given at this office visit. He is due for Hep B vaccine. I will provide educational materials in regards to Hep B vaccine.
• Return to office in 3 days for weight check and if weight increasing will offer Hep B vaccine.
• Keep the child in upright position after feeding to minimize regurgitation.
• Call the office if any questions arise.
• Discussed newborn care.
• Discussed appropriate car seat

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