NUR 112/NUR112 Labor-Vaginal Delivery Case Study - UNFOLDING Reasoning

Labor-Vaginal Delivery UNFOLDING Reasoning Anne Jones, 17 years old Primary Concept Pain Interrelated Concepts (In order of emphasis) 1. Perfusion 2. Stress 3. Anxiety 4. Reproduction 5. Clinical Judgment 6. C ...

Labor-Vaginal Delivery UNFOLDING Reasoning Anne Jones, 17 years old Primary Concept Pain Interrelated Concepts (In order of emphasis) 1. Perfusion 2. Stress 3. Anxiety 4. Reproduction 5. Clinical Judgment 6. Communication 7. Collaboration NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment • Management of Care 17-23% ✓ • Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12% ✓ Psychosocial Integrity 6-12% ✓ Physiological Integrity • Basic Care and Comfort 6-12% ✓ • 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. History of Present Problem: Anne is a 17-year-old, gravida 1 para 0 who is 39 weeks gestation and admitted to the labor room for observation at 1200. She began having contractions three hours ago at 8 to 10-minute intervals with each contraction lasting 30 seconds. She states her pain is 3/10. Her membranes are intact. On admission, a vaginal exam indicates cervical dilation is 1 cm, 80% effacement, and 0 station. After two hours of observation, her cervix is 2-3 cm/ 80% effacement/0 station and contractions are now 4- 5 minutes apart, lasting 60-70 seconds and pain remains 3/10. Fetal lie is longitudinal with a cephalic presentation. You have her prenatal records from her visits to the office. She is Group Beta Strep (GBS) positive and received antibiotics at 36 weeks. Her blood type is B-. Personal/Social History: Anne’s mother is with her. Anne is not married and the father of the baby is not involved. She appears to be relaxed although she states she is a bit nervous. She wants a natural non-medicated birth and her mother will help coach her. She plans on breastfeeding for “awhile”. She attended childbirth preparation classes with her mother. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: RELEVANT Data from Social History: Clinical Significance: Anne is placed on a fetal monitor and the nurse collects the following strip: Pt is 17 y.o., gravida 1 para 0 and 39 weeks gestation. Began having contractions 3 hrs ago at 8-10 min intervals lasting 30 secs. Pain is a 3/10 Membranes are intact. Cervical dilation is 1 cm, 80% effacement and 0 station. 2 hours later her cervix is 2-3 cm, 80% effacement and 0 station. Contractions are now 4-5 mins apart lasting 60-70 secs Fetal lie is longitudinal with a cephalic presentation. She is GBS positive and received antibiotics at 36 weeks Blood type is BPt’s mom is present but baby’s father is not involved. She appears relaxed but states she is a bit nervous. Pt wants. natural non medicated birth. The patient plans on breastfeeding Mom will help coach pt through birth Pt and mother attended childbirth prep classes. Age, gravida, para, and gestational age could all be risk factors for pregnancy/ labor complications. Contractions lasting 8-10 mins for 30 secs does not indicate labor, we should perform vaginal exam to check for cervical changes indicating labor. These could also be Braxton Hicks Contractions. indicates the pts pain is well under control. The intact membrane means the pt is not in active labor and the water hasn’t broken. The cervical still needs to dilate 9cm, effaced to 90%, and station should be +3. The increase in cervical dilation and contractions can indicate the onset of labor. This means the baby is in appropriate positioning for birth. This indicates the mother will need another dose of treatment during labor. It is important to know the blood type incase of any complications. Although the father is not present, the pt and baby still have a good support system through the pt’s mother. The pt might need some extra comforting support to settles her nerves Nurses will have to use natural methods of pain control for pt. The patient will need education on breastfeeding prior to discharge. The pt will have comforting and support from mom through birth The pt and mother have taken the time to prepare themselves and are likely ready for the labor process. Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. Fetal Heart Rate Strip Assessment: Fetal Monitoring Strip: Interpretation: Clinical Significance: Patient Care Begins: What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: Current VS: P-Q-R-S-T Pain Assessment: T: 98.6 F/37.0 C (oral) Provoking/Palliative: Began 3 hours ago P: 76 (regular) Quality: Cramping that comes and goes, lasting 40 sec after 1 hour 60- 70 sec. R: 18 (regular) Region/Radiation: Uterus BP: 125/80 Severity: 3/10 O2 sat: 98 Timing: 8-10 min then 4-5 mins Temp 98.6 F Pulse 76 Resp 18 BP 125/80 O2 Stat 98 RA 3/10 pain Cramping comes and goes, lasting 40 secs, after 1 hr lasting 60-70 secs. The vital signs are all within normal limits and indicate the patient is not under any distress and there are no complications so far. The patient is experiencing 3/10 pain in her uterus which is minimal. The timing of the contractions are becoming more frequent and lasting longer. 135 baseline FHR, Moderte variability w/ accelerations no decelerations present. Contractions are every 2-3 mins and last 50-80 seconds. Indicates fetal well being Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT Assessment Data: Clinical Significance: Clinical Reasoning Begins… 1. Interpreting relevant clinical data, what is the primary concern? What primary health-related concepts does this primary problem represent? (Management of Care/Physiologic Adaptation) Problem: Pathophysiology of Problem in OWN Words: Primary Concept: Collaborative Care: Medical Management (Pharmacologic and Parenteral Therapies) Care Provider Orders: Rationale: Expected Outcome: Admit to Labor and Delivery Intermittent fetal heart monitoring ambulating as tolerated Ampicillin 2 g IVPB when in active labor and 1 g every 4 hours while in labor Current Assessment: General Appearance: Calm, body relaxed, no grimacing, appears to be slightly anxious. Respiratory: Breath sounds clear with equal aeration bilaterally ant/post, non-labored respiratory effort Cardiac: Pink, warm & dry, slight ankle edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial, brisk cap refill Neuro: Alert and oriented to person, place, time, and situation (x4)