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Running head: S. STABLES, NUTRITION CARE PLAN Sloane Stables Integrated Care Plan: Imbalanced Nutrition, Less Than Body Requirements NURS 4560: Transition to Professional Nursing Practice Tarleton State University Diana Kunce-Collins, MS RNC-MNN October 2, 2016
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S. STABLES, NUTRITION CARE PLAN 2 Integrated Care Plan: Imbalanced Nutrition, Less Than Body Requirements Patient History: CU is a neonate that was born via vaginal delivery at 0828 on 9/20/2016. Hospital day #1. Gestational Age 39 weeks. No problems during delivery. Apgar scores were 8 and 9. Weighed 6 lbs. 4.9 oz and was 18 inches. No maternal tobacco, ETOH, or illicit drug use. Mother was gestational diabetic with no other significant medical history. Medications while in the hospital included Vitamin K injection, Hepatitis B vaccine, and Erythromycin ophthalmic ointment. S: Patient was irritable during assessments with a high-pitched cry. Mother stated that the infant was constantly shivering. Poor suck and feeding when breastfeeding initiated. The infant continuously falls asleep while breastfeeding and goes back to sleep within minutes of arousal. O: Capillary blood glucose reading of 31 mg/dL that increased to 63 mg/dL when given 1oz formula. Skin warm and pink with mild acrocyanosis. Brisk capillary refill. Nail beds blanch with pressure. Apgar Scores of 8 and 9. HR remains steady at 132 bpm, RR steady at 48, Temperature 97.9 F.
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