\Sabel\an Texrtendez
Normal Newborn
SKINNY Reasoning
Baby Boy Jones, 1 hour old
rimary Concep
______Reproduction I I
. Interrelated Concepts (In order
of emphasis)
Thermoregulation
® Nutrition
Perfusion
Pain
Clinical Judgment
Patient Education
Communication
Collaboration
| Percenta Items from
of ge Covered
_Each Category/ inCase
Safe and Effective Care Environment . ... . .
® Management of Care 17-23% v
* Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12%
<A
Psychosocial Integrity 6-12%
Physiological Integrity : .
® Basic Care and Comfort 6-12%
slalsie]
® Pharmacological and Parenteral Therapies 12-18%
° Reduction of Risk Potential 9-15%
* Physiological Adaptation 11-17%
Copyright© 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
, SKINNY Reasoning _
Part I: Recognizing RELEVANT Clinical Dat
History of Present Problem
One hour after Delivery:
Anne is a 17-year-old, gravida 1 para 1 who is 39 weeks gestation. She recently experienced a normal spontaneous
vaginal delivery on 6/12/2020 at 2300 without the use of pain medications or an epidural. She came in to labor on
6/12/2020 at 0600 stating she had broken her water yesterday at noon. She delivered a baby boy who was placed skin to
skin following delivery. You assign Apgars of 8 and 9. Baby voided right after delivery and is due to stool. Weight: 7 Ibs.
0 oz. (3.2 kg),20 inches (50.8 cm) long. After he had his first feeding, erythromycin ointment was applied to his eyes.
Vitamin K and hepatitis B vaccine (after consent given) were administered in right and left thigh in the outer aspect of
the left thigh.
Ann is Group Beta Strep (GBS) positive and received antibiotics 3 doses before delivery, blood type is B-, and rubella
positive. Cord blood was sent.
Personal/Social History: -
Anne has her mother with her for support. She seems to be tired but is holding and interacting with the baby
appropriately. The father of the baby is not involved. Anne plans on breastfeeding for “awhile.” Anne still lives athome,
and her mother plans to help with the new baby and appears supportive.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction ofRiskPotential) ‘ A ‘ o L
RELEVANT Data fromReport: | Clinical Significance:
Ty o, Gl Pl - 20w geo |~ OEQRONY OFCe, Eisk Onid
DOV 5P0M. (oGRaON dehivexy ~ Q000G e wDorh nealvn
NG oMV Blood Hpe B- |7 'Ong lamer Wil Mo poun eds o onCSRNeT&
250¢ \OOo¢ S OB R QASTNNG X NELIO SV, T SONT
_CY
z\%‘%?f ERE - POrenol, v, Sekecis
o —
Data from Social History:
RELEVANT | Clinic: pificance:
- POCRCRN™D SUDPOYWE, ~ OSASNOA BeORert | coe.
~fokaer W Oy ‘“\V@-Vfié - OGNS e\ OOy
TONOS Seedvngy ~ ORCOOIBL; was Ko oo
ol
0K
‘El:i f:}g;‘f?‘ 75 e
YoM, o
ook, com%c»(*\m%,
- %
EXMAGL OSEINSHRO(WE O NomC
PO & "g’:mm\
Patient Care Begins: You complete your assessment:
Curremtvs: | P-QRSTPainAsessment:
T: 97.‘0 F/36.1 C (axillary) Provoking/
P: 130 (regular) Quality:
R: 50 (irregular) Region/
BP: none taken Severity: NIPS score 0
02 sat: pink in color/no central Timing;
cyanosis noted w/ acrocyanosis
Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
Normal Newborn
SKINNY Reasoning
Baby Boy Jones, 1 hour old
rimary Concep
______Reproduction I I
. Interrelated Concepts (In order
of emphasis)
Thermoregulation
® Nutrition
Perfusion
Pain
Clinical Judgment
Patient Education
Communication
Collaboration
| Percenta Items from
of ge Covered
_Each Category/ inCase
Safe and Effective Care Environment . ... . .
® Management of Care 17-23% v
* Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12%
<A
Psychosocial Integrity 6-12%
Physiological Integrity : .
® Basic Care and Comfort 6-12%
slalsie]
® Pharmacological and Parenteral Therapies 12-18%
° Reduction of Risk Potential 9-15%
* Physiological Adaptation 11-17%
Copyright© 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
, SKINNY Reasoning _
Part I: Recognizing RELEVANT Clinical Dat
History of Present Problem
One hour after Delivery:
Anne is a 17-year-old, gravida 1 para 1 who is 39 weeks gestation. She recently experienced a normal spontaneous
vaginal delivery on 6/12/2020 at 2300 without the use of pain medications or an epidural. She came in to labor on
6/12/2020 at 0600 stating she had broken her water yesterday at noon. She delivered a baby boy who was placed skin to
skin following delivery. You assign Apgars of 8 and 9. Baby voided right after delivery and is due to stool. Weight: 7 Ibs.
0 oz. (3.2 kg),20 inches (50.8 cm) long. After he had his first feeding, erythromycin ointment was applied to his eyes.
Vitamin K and hepatitis B vaccine (after consent given) were administered in right and left thigh in the outer aspect of
the left thigh.
Ann is Group Beta Strep (GBS) positive and received antibiotics 3 doses before delivery, blood type is B-, and rubella
positive. Cord blood was sent.
Personal/Social History: -
Anne has her mother with her for support. She seems to be tired but is holding and interacting with the baby
appropriately. The father of the baby is not involved. Anne plans on breastfeeding for “awhile.” Anne still lives athome,
and her mother plans to help with the new baby and appears supportive.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction ofRiskPotential) ‘ A ‘ o L
RELEVANT Data fromReport: | Clinical Significance:
Ty o, Gl Pl - 20w geo |~ OEQRONY OFCe, Eisk Onid
DOV 5P0M. (oGRaON dehivexy ~ Q000G e wDorh nealvn
NG oMV Blood Hpe B- |7 'Ong lamer Wil Mo poun eds o onCSRNeT&
250¢ \OOo¢ S OB R QASTNNG X NELIO SV, T SONT
_CY
z\%‘%?f ERE - POrenol, v, Sekecis
o —
Data from Social History:
RELEVANT | Clinic: pificance:
- POCRCRN™D SUDPOYWE, ~ OSASNOA BeORert | coe.
~fokaer W Oy ‘“\V@-Vfié - OGNS e\ OOy
TONOS Seedvngy ~ ORCOOIBL; was Ko oo
ol
0K
‘El:i f:}g;‘f?‘ 75 e
YoM, o
ook, com%c»(*\m%,
- %
EXMAGL OSEINSHRO(WE O NomC
PO & "g’:mm\
Patient Care Begins: You complete your assessment:
Curremtvs: | P-QRSTPainAsessment:
T: 97.‘0 F/36.1 C (axillary) Provoking/
P: 130 (regular) Quality:
R: 50 (irregular) Region/
BP: none taken Severity: NIPS score 0
02 sat: pink in color/no central Timing;
cyanosis noted w/ acrocyanosis
Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
