a.

Demographic and Patient Profile This is the case of Baby Maly, 29 day old old and the first child of Ms. Maly and her common law husband Mr. Maly, both Filipino Citizen and Catholics. His mother, 16 years old, was admitted at JFH last October 29, 2013 with an admitting diagnosis of Gravida 1 Para 0 Pregnancy Uterine 39 4/7 weeks age of gestation by last menstrual period (January 25, 2013) ; Frank breech; in labor.

Ms. Maly absconded and left the hospital without permission last November 8, 2013, leaving Baby Maly at the hospital's NICU. This case was already reported and referred to the hospital's MSW for them to locate Ms. Maly or other relatives but still no updates.

According to Ms. Maly's chart, she is did not finished high school and lives in Manila. She is a housewife to her common law husband, 20 years old, who works as a houseboy.

b. History of Past and Present Illness

Baby Maly was born at Jose fabella Hospital via Cesarean Section last October 29, 2013. Upon the pediatrician's assessment, Baby Maly's APGAR score was 7at the first minute of life and a score of 9 after 5 minutes. He weighs 2580 grams which was appropriate for his gestational age; has leaking meningocele at his lumbar area, has complete bilateral cleft lip, palate and with mild retractions. He was then admitted in JFH Neonatal Intensive Unit with an admitting diagnosis of Multiple Congenital Anomaly.

During Ms. Maly's pregnancy, as per chart review, she did not went for pre natal checkups; no ultrasound; no immunization of tetanus toxoid; no intake of multivitamins, ferrous sulfate and folic acid. She is also a smoker.

c. Family Health History Baby Maly's grandfather from the maternal side was diagnosed hypertensive while his maternal grandmother is suffering from diabetes mellitus. These diseases from the family health history are not known to contribute to baby Chars condition. However, health history of his father's side were not gathered since data were collected from Ms. Maly's chart,

Genogram

d. Diagnostics Complete Blood Count - (CBC) is one of the most commonly ordered blood tests. It was ordered to determine patients general health status. Provides useful clinical information. The initial blood counts and and follow up of this order serves as a guide for Baby Maly's health care provider to monitor the effectiveness of intervention rendered and the prognosis of Baby Maly's condition.

Results 10/29/13 Hemoglobin Hematocrit RBC Count WBC Count 169 .49 4.92 9.5 11/4/13 172 .51 5.32 10.8 11/7/13 162 .43 4.23 12.5

Normal Values 11/18/13 147 .53 4.18 14.8 140 180 g/L 0.4-.54 3.9-5.5 x10^12/L 3-19.5 x10^9/L

Neutrophils Lymphocyte Basophils Monocytes Platelet Count

0.38 0.31 0.00 0.01 139

0.53 0.23 0.00 0.00 137

0.52 0.28 0.00 0.00 128

0.60 0.30 0.00 0.02 142

0.00-0.61 0.00-0.31 0.00-0.01 0.00-0.03 150-400 x10^9/L

Analysis: As reflected in the table, Baby Maly has normal hemoglobin, hematocrit, RBC, WBC counts. However, his platelet counts are slightly decreased all throughout the treatment course. Platelet count of newborns are slightly decreased but will eventually be at normal level at 3 months of age.

Arterial Blood Gas - ( ABG) test measures the acidity (pH) and the levels of oxygen and carbon dioxide in the blood from an artery. This test used to find out if Baby Maly receiving the right amount of oxygen. Results 10/30/13 pH pCo2 pO2 O2 Saturation 4.6 18.5 150.5 99.1 7.35-7.45 35-45 mmHg 80-100 mmHg 97-100% Normal Values

Analysis: It is shown in the table that, Baby Maly is suffering from respiratory alkalosis maybe the reason why he has mild retractions.

Blood Culture and Sensitivity - a is a test to detect germs such as bacteria or fungi in the blood. Results of blood c and s takes up to few days that is why treatment such as antibiotics can be given even before the results are completed.

Results 10/30/13 Organism: No growth after 5 days (November 3 2013)

Analysis: The result for Baby Maly's blood culture and sensitivity reveals no growth of organisms. e. Medical Management Oxygen Therapy - Oxygen supplementation is an important component of intensive care of the newborn. As for Baby Maly, it is noted that he has mild retractions upon assessment, as a result, he needs initial assistance to correct his breathing pattern Patients response and selected interventions

Treatment

Date ordered Date performed Date changed or discontinued Date Ordered: 10-29-13 Date Performed: 10-29-13 D/C: 10-30-13

Indication/ Purpose

Oxygen Hood at 8 lpm

> used for newborns who can breathe on their own but still need extra oxygen.

>Patient' s breathing pattern improved; did not show any sign of respiratory distress

Oxygen Hood at 6 lpm

Date Ordered: 10-30-13 Date Performed: 10-30-13 D/C: 10-30-13

> for oxygen hood weaning

> tolerated, did not show any sign of respiratory distress

Oxygen administration via Nasal Cannula at 1 lpm

Date Ordered: 10-30-13 Date Performed: 10-30-13 D/C: 10-31-13

> in preparation for discontinuing of oxygen therapy.

> Upon shifting to nasal

cannula, the patient did not show any signs and symptoms of respiratory distress.

Medications Date ordered Patients response

Drug name

Date given Date changed or discontinued

Route, dosage, frequency

Classification and Indication

Generic Name: Ceftazidime

DO: 10-29-13 DC: 11-11-13

80 mg SIVP Q12

C: Third-generation cephalosporin I: used in suspected sepsis.

>Patient did not develop infection.

Generic Name: Oxacillin

DO: 10-29-13 DC: 11-11-13

130 mg SIVP Q12

C: Penicillin I: used to initiate therapy in suspected cases of resistant staphylococcal infections prior to the availability of susceptibility test results.

>Patient did not develop infection.

Generic Name: Amikacin

DO: 10-29-13 DC: 11-12-13

38 mg IV OD

C: Aminoglycoside I : indicated in the short-term treatment of serious infections due to susceptible strains of Gramnegative bacteria

>Patient did not develop infection.

Intravenous Fluid Therapy - Fluid, electrolyte, and nutrition management is important because most infants in a neonatal intensive care unit (NICU) require intravenous fluids (IVFs) and have shifts of fluids between intracellular, extracellular, and vascular compartments

Treatment

Date ordered Date performed Date changed or discontinued Date Ordered: 10-29 Date Performed: 10-29-13 D/C: 11-3-13

Indication/ Purpose

D5W 55cc regulated at 67 cc/hr

> Dextrose 5% in water is given for nutritional support to patients who are unable to eat because of illness, injury, or other medical condition.

f. Pathophysiology g. Course in the Ward October 29, 2013 Upon assessment of the pediatrician, the patient was then admitted to the NICU, placed under oxygen hood, started medications and diagnostic procedures. Admission to 1st week (October 29, 2013- November 4, 2013) Still with mild subcostal chest retractions Meningocele covered with soaked OS and covered with plastic October 30, 2013 9:35 am, inserted OGT; Patient started gavage feeding of 5 cc of breastmilk every 3 hours weaned 02 hood at 6 lpm; tolerated Doctor ordered cranial ultrasound- not done due to financial problems at 12 noon, shifted O2 hood to nasal cannula 1 lpm; tolerated refered to JRRMMC Hospital for

possible transfer 8pm, JRRMMC informed JFH that there is no vacancy; continued present

managemnet October 31, 2013 3:10 pm, discontinued O2 therapy, no retractions noted; tolerated increased GF to 10cc every 3 hours; tolerated 9pm, increased GF to 15 cc every 3 hours; tolerated November 1, 2013 6 am, continued Gavage feeding of 15cc of breastmilk every 3 hours; tolerated (+) leaking meningocele, replaced leaks with PNSS 25cc via IV push November 2, 2013 7:10 am, increased Gavage feeding of 15cc to 30cc of breastmilk every 3 hours; tolerated November 3, 2013 3:10 am, increased Gavage feeding of 30cc to 35cc of breastmilk every 3 hours; tolerated IVF discontinued heplock for medications placed Final blood c and s revealed no growth

November 4, 2013 8:45 am, increased Gavage feeding of 40cc to 45cc of breastmilk every 3 hours; tolerated repeat CBC done, no unusual findings

 November 5, 2013 continued gavage feeding of 45cc of breastmilk; tolerated November 6, 2013 continued gavage feeding and medications November 7, 2013 continued gavage feeding and medications cbc done, no unsusual findings November 8, 2013 2nd Week (November 5, 2013- November 11, 2013) continued gavage feeding and medications mother absconded; refered to MSW November 9, 2013 continued gavage feeding and medications November 10, 2013 continued gavage feeding and medications cbc done, no unsusual findings November 11, 2013 continued gavage feeding Amikacn discontinued Ceftazidime and Oxacillin continued

3rd Week (November 12, 2013- November 18, 2013)

November 12, 2013 last dose of medications given; medication discontinued heplocked removed

refered patient to social service gavage feeding continued

November 13, 2013 continued gavage feeding November 14, 2013 continued gavage feeding follow up of referal to social worker done

November 15, 2013 continued gavage feeding follow up of referal to social worker done

November 16, 2013 continued gavage feeding follow up of referal to social worker done

November 17, 2013 continued gavage feeding follow up of referal to social worker done

November 18, 2013 continued gavage feeding CBC done, no unusual findings follow up of referal to social worker done

November 19, 2013 continued gavage feeding follow up of referal to social worker done

November 20, 2013 continued gavage feeding follow up of referal to social worker done 4th Week (November 19, 2013- November 25, 2013)

November 21, 2013 continued gavage feeding follow up of referal to social worker done

November 22, 2013 continued gavage feeding

follow up of referal to social worker done

November 23, 2013 continued gavage feeding follow up of referal to social worker done

November 24, 2013 continued gavage feeding follow up of referal to social worker done

November 25, 2013 continued gavage feeding follow up of referal to social worker done Clinically, patient is stable, with negative retractions, active and good cry, good cardiac tone, with full pulses, but still with leaking meningocele f. Nursing Health Assessment (Gordons Functional Health Patterns)

Health Perception and Management

Nutritional metabolic Elimination

Activity and Exercise

Cognitive-perceptual

Sleep/Rest

Role relationship

Sexuality and Reproduction

Self perception/self concept

Coping-stress tolerance

Value-Belief Pattern