TASK 18: You are a Maternal and Child Health Nurse working at the Romaville Community Child Health Service. Today’s date: 15 January 2012
Patient History Baby boy: Dylan Charles
DOB: 04/12/11
Born: Romaville Maternity Hospital. First baby of Raymond and Sylvia Charles
Address: 19 Mayfield St, Romaville.
Discharged: 08/12/11
Family History
Mother: Aged 24 First Child, Father: Aged 25 Soldier Currently away from home on duty
Birth History: Normal vaginal birth at term, Birth weight: 3400gm, Apgar score at 5 min: 9
No antenatal or postnatal complications
15/01/12 Subjective
Silvia and baby attended for routine 6 week check-up. Silvia says she is concerned about constipation: once every three days, hard stool. Mother is asking about stool Softener or prune juice for baby
Breast fed for first three weeks after birth
Baby become unsettled during summer heatwave in December.
Silvia got sick and had a fever for a few days. Mother-in-law (Mary Charles) came to visit and advised changing baby to formula feeds. Mary advised extra powder in formula feeds to improve weight gain.
Silvia worried she does not have enough breast milk and now gives extra formula feeds as well as breast feeding. Dylan difficult to bottle feed.
Silvia wishes to breast feed properly as she believes it would be the best thing for her son
Mary Charles plans to stay with the family for at least a further month to help with baby. Tensions developing between mother and mother-in-law over what is best feeding method for Dylan.
Objective
Reflexes normal, Slightly lethargic, No abdominal tenderness, Heart Rate: 174, Respirations: 56, Temperature: 37.1, Weight: 4200gms, 3 wet nappies in last 24 hours, Urine dark:
Assessment: Mild constipation and dehydration
Plan: Increase breast feeds
Refer to breast feeding support service, Check formula is correctly prepared, If continuing formula feeds, advise to supplement with water (boiled and cooled). Advise on keeping baby cool in hot weather
Return for review in 48 hours.
Writing Task: Please write a referral letter to the Lactation Consultant at the Breast Feeding Support Centre, 68 Main Street Romaville
View sample answer by Lifestyle Training Centre
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