Antepartum Care UNFOLDING Reasoning ; Anne Jones is a 17-year-old (complete case study)

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Antepartum Care UNFOLDING Reasoning Primary Concept Reproduction Interrelated Concepts (In order of emphasis) 1. Nutrition 2. Patient Education 3. Stress 4. Coping 5. Clinical Judgment 6. Co... mmunication 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. Anne Jones , 17 years old History of Present Problem: Anne Jones is a 17-year-old Caucasian teenager who thinks she may be pregnant because she has missed two periods. Her last menstrual period, she thinks, was about one month ago. She states she had a little bit of spotting last week but didn’t have a “full period”. She complains of her breasts being tender, swollen, frequent urination, and nausea in the morning. This is her first office visit and she is not sure why she feels so crummy but suspects she might be pregnant. Her urine pregnancy test is positive. Her primary care provider orders a prenatal lab panel and a urinalysis. Personal/Social History: Anne is a senior in high school who stands on her feet while working at McDonalds after school. She drinks six colas daily, denies alcohol use, and does not smoke. She takes no medications except for occasional acetaminophen for headaches and ibuprofen for menstrual cramps. Anne is 5’4” (160 cm) and weighs about 105 lbs. (47.7 kg) according to Anne. A 24-hour recall nutrition history reveals a typical day’s diet: breakfast- pop tart and can of cola; Lunch- a slice of pizza, chocolate chip cookie, can of cola; Dinner- fried chicken, green beans, biscuit, can of cola; snacks, including cookies and can of cola. She broke up last week with her boyfriend, and he is not aware she might be pregnant. She wants to keep the baby but has not told her parents. 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: Amenorrhea Positive pregnancy test Breasts being tender, swollen, frequent urination, and nausea Ht. 5”4 (160 cm) Wt. 105 lbs. (47.7 kg) Breakfast- pop tart and can of cola; Lunch- a slice of pizza, chocolate chip cookie, can of cola; Dinner- fried chicken, green beans, biscuit, can of cola; snacks, including cookies and can of cola. Earliest symptom of pregnancy This test checks for the presence of “detectable” amounts of HCG hormone which is secreted by the fertilized egg which is implanted on the endometrium. These are subjective (presumptive) changes, that could indicate pregnancy. This patients BMI is 18, which indicates she is underweight Inadequate intake of nutrients. Lack of prenatal vitamins. At risk for hypertension due to inadequate fluid intake. At risk for gestational diabetes and other health problems associated with diets high in sugars, processed, and fried foods. RELEVANT Data from Social History: Clinical Significance: Patient is a minor, Age 17 She broke up last week with her boyfriend, and he is not aware she might be pregnant. She wants to keep the baby but has not told her parents. Anne is a senior in high school who stands on her feet while working at McDonalds after school This patient is a minor and her parents will need to be contacted in order to provide (legally) further treatment. Patient is alone and does not have emotional support. Also this patient is a risk of experiencing challenges with her education and social wellbeing. Standing on her feet at a laborious job that does not provide adequate health insurance or accommodations for pregnant women may impact her health adversely. Standing for long periods is difficult for pregnant women at risk for DVT. Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 98.6 F/37.0 C (oral) Provoking/Palliative: Breast tenderness P: 76 (regular) Quality: Tender to touch and movement R: 18 (regular) Region/Radiation: Both breasts BP: 125/80 Severity: 4/10 but better if wears a bra O2 sat: not assessed Timing: For the past couple of months 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: Breast tenderness Changes in the breast are frequently noted in early pregnancy. Engorgement of the breast due to hormone induced growth of the secretory ductal system results in subjective symptoms of tenderness and tingling, especially in the nipple area. The patient is educated about the importance of wearing comfortable bras. Current Assessment: GENERAL APPEARANCE: Calm, body relaxed, no grimacing, appears to be slightly nervous, Height 5’4” (160 cm), weight 100 lbs. (45.5 kg), 5 lbs. (2.3 kg) weight loss from pre-pregnant weight, no appetite. BMI 18 RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort CARDIAC: Pink, warm & dry, no 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) HEENT: Normal cephalic, slight bleeding at gum lines. Conjunctiva of eyelids; appears pale Chest: Breasts tender on palpation, areola darkened and occasional veins present Abdomen: Soft; no masses, uterus palpable below the level of the symphysis pubis, Extremities: Mild spider varicose veins on the medial aspect of the left leg, deep tendon reflexes 2+ Pelvic Exam: Vagina and cervix deep purple in color, uterus slightly enlarged, and Hegar’s sign present 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: Low BMI 5 lbs of weight loss Bleeding gums, Tender breast, Dark areolas Uterus palpable below the level of the symphysis pubis LL spider varicose veins, deep tendon reflexes 2+ Deep purple in color, uterus slightly enlarged Low BMI and weight loss is significant because the patient has inadequate nutritional intake and needs supplementation with prenatal vitamins and education about proper caloric increase during each trimester of pregnancy. Objective (probable) changes that occur in pregnancy Chadwick sign, Hegar sign, enlargement of the abdomen, Braxton hicks contractions, uterine soufflé, changes in pigmentation of the skin, fetal outline, pregnancy test. Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. Hegar sign Lab Results: Prenatal Panel Hemoglobin RPR/VDRL HBsAG Blood type Rubella HCG ELISA Current: 11.0 mg/dL Negative Negative B- Nonimmune 20,700 mlU/ml Negative What lab results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: 11.0 mg/dL Rubella (nonimmune) Low hemoglobin is a indication of iron deficiency and places the patient at risk for preterm delivery, anemia, and low birth weight Rubella has teratogenic effects on fetal development, and places the patient at risk for preterm birth. Prevention is possible by vaccination but contraindicated in pregnant women due to the risk of birth defects and preterm delivery Worsening Improve Urine Dipstick Color: Clarity: Sp. Gr. Protein Glucose Ketones Leukocytes/Nitrite Blood Chlamydia Gonorrhea Current: Yellow Clear 1.010 neg neg neg none none positive What lab results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: Chlamydia Gonorrhea during pregnancy(+) Chlamydial infection is the most frequently reported infectious disease in the United States, and prevalence is highest in persons aged ≤24 years (118). Several sequelae can result from C. trachomatis infection in women, the most serious of which include PID, ectopic pregnancy, and infertility Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. Lab Planning: Creating a Plan of Care with a PRIORITY Lab (Reduction of Risk Potential/Physiologic Adaptation) Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: HGB: 11.0 Critical Value: Low hemoglobin is a indication of iron deficiency and places the patient at risk for preterm delivery, anemia, and low birth weight Supplementation to promote erythropoietin, oxygen therapy if saturation is <90% Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: Chlamydia Gonorrhea POSITIVE Critical Value: Chlamydial infection is the most frequently reported infectious disease in the United States, and prevalence is highest in persons aged ≤24 years (118). Several sequelae can result from C. trachomatis infection in women, the most serious of which include PID, ectopic pregnancy, and infertility  Ceftriaxone 25–50 mg/kg IV or IM in a single dose, not to exceed 125 mg  Doxycycline 100 mg orally twice a day for 7 days 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: Physiology of Changes in OWN Words: Primary Concept: STD infection Pregnancy Sexually transmitted diseases during pregnancy places the patient and fetus at risk of complications such as premature birth, birth defects, and other adverse outcomes. Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. Collaborative Care: Nursing 2. What nursing priority (ies) will guide your plan of care? (Management of Care) Nursing PRIORITY: PRIORITY Nursing Interventions: Rationale: Expected Outcome: Administer antibiotics indicated for pregnant women with Gonorrhea and Chlamydia Treating the infection reduces the chances of it spreading to pelvic anatomy and negatively affecting pregnancy and developing fetus. Patient will have a negative Gonorrhea and Chlamydia test in 7 days when retesting is recommended 3. What body system(s) will you assess most thoroughly based on the primary/priority need? (Reduction of Risk Potential/Physiologic Adaptation) PRIORITY Body System: PRIORITY Nursing Assessments: The reproductive system and circulatory system Maternal and fetal BP and heart rate, temperature, fundal height 4. What is the worst possible/most likely complication(s) to anticipate based on the primary need for this patient? (Reduction of Risk Potential/Physiologic Adaptation) Worst Possible/Most Likely Complication to Anticipate: Nursing Interventions to PREVENT this Complication: Assessments to Identify Problem EARLY: Nursing Interventions to Rescue: Preterm delivery Fetal monitoring BEDREST, antibiotics, supplementation with iron 5. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity/Basic Care and Comfort) Psychosocial PRIORITIES: PRIORITY Nursing Interventions: Rationale: Expected Outcome: CARE/COMFORT: Caring/compassion as a nurse Physical comfort measures Support the patients decision to keep her baby, help the patient elevate her legs Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. EMOTIONAL (How to develop a therapeutic relationship): Discuss the following principles needed as conditions essential for a therapeutic relationship: Speak calmly with a non-judgmental tone • Rapport • Trust • Respect • Genuineness • Empathy Lack of support system Unplanned pregnancy Reassure the patient that she will receive care necessary to promote a healthy pregnancy Refer the patient to parenting classes and support groups, birthing classes SPIRITUAL: Ask the patient if she has any religious preferences CULTURAL Considerations (IF APPLICABLE) Ask the patient about her beliefs around pregnancy, and child birth TWELVE-WEEKS LATER… Anne returns to the office for her fourth visit. She is now 20 weeks pregnant. She states her morning sickness has gotten better and she felt the baby move a few weeks ago. She has gained 10 lbs. (4.5 kg) since the first visit. She had her MFAP and triple marker blood screening labs drawn at 16 weeks which was negative. She has told her parents, and they are supportive. She also told her boyfriend, but he has no interest to be involved. RELEVANT Data: Clinical Significance: Patient has gain 10 lbs MFAP negative She has a support system Proper nourishment is occurring, patient BMI is within normal limits. No birth defects. Patient support system is in tact Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. Current VS: First visit: Current PQRST: T: 98.6 F/37.0 C (oral) 98.6 F/37.0 C (oral) Provoking/Palliative: Standing for long time P: 80 (regular) 76 (regular) Quality: Dull R: 18 (regular) 18 (regular) Region/Radiation: Lower back BP: 120/70 125/80 Severity: Mild, 3/10 O2 sat: not assessed not assessed Timing: occasional Current Assessment: GENERAL APPEARANCE: Calm, body relaxed, no grimacing, appears to be resting comfortably RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds regular with soft murmur heard at the left sternal border, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill NEURO: Alert and oriented to person, place, time, and situation (x4) HEENT: Normal cephalic, slight bleeding at gum lines. Conjunctiva of eyelids appear pale Chest: Breasts tender on palpation, areola darkened and occasional veins present Abdomen: Soft; no masses, uterus palpable at midway between symphysis pubis and umbilicus, light linea nigra present Extremities: Mild spider varicose veins on the medial aspect of the left leg, deep tendon reflexes 2+ Fetal Heart Rate: 150 bpm, Lower Left Quadrant (LLQ) Lab Results: Prenatal Labs Hemoglobin RPR/VDRL HBsAG Blood type Rubella HCG MFAP Triple Marker Current: 10.1 mg/dL Normal Negative Most Recent: First visit 11.0 mg/dL Positive Negative B- Nonimmun e 20,700 mlU/ml 1. What data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: Standing for long time Dull Lower back Mild, 3/10 occasional The spine is stressed by the growing fetus and causes discomfort in the lower/lumbar back, RELEVANT Assessment Data: Clinical Significance: Pink, warm & dry, no edema, heart sounds regular with soft murmur heard at the left sternal border, pulses strong, equal with palpation at radial/pedal/posttibial landmarks, brisk cap refill Heart murmurs during pregnancy may be due to the increased volume of blood flowing through the heart RELEVANT Lab Data: Clinical Significance: RPR/VDRL Positive Parenteral penicillin G is the only therapy with documented efficacy for syphilis during pregnancy. Pregnant women with syphilis in any stage who report penicillin allergy should be Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. desensitized and treated with penicillin (see Management of Persons Who Have a History of Penicillin Allergy). 2. Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? (Management of Care, Physiological Adaptation) Evaluation of Current Status: Modifications to Current Plan of Care: The patients condition has improved with some complication Extensive education about STDs and infection prevention 3. Based on your current evaluation, what are your CURRENT nursing priorities and plan of care? (Management of Care) CURRENT Nursing PRIORITY: PRIORITY Nursing Interventions: Rationale: Expected Outcome: Administer medication to treat infection Prevent adverse outcomes such as preterm birth Patient will have negative syphilis test Education Priorities/Discharge Planning What educational/discharge priorities will be needed to develop a teaching plan for this patient and/or family? (Health Promotion and Maintenance) Education PRIORITY: PRIORITY Topics to Teach: Rationale: Sex education, nutritional wellness, medication safety, and effective use of antibiotic medication, identifying signs of premature labor. Patient has a multiple incidence of STD with the this pregnancy further teaching mat prevent future infections. Nutritional wellness education is essential throughout pregnancy to promote the health of the mother and developing fetus. Educating patient about the importance of taking antibiotics as prescribed to ensure the infectious organism is eradicated. Caring and the “Art” of Nursing What is the patient likely experiencing/feeling right now in this situation? What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a person? (Psychosocial Integrity) What Patient is Experiencing: How to Engage: The patient is probably embarrassed about the infections. She may also be physically uncomfortable with all of the rapid changes happening to her body Be non-judgmental, use open-ended questions, use a calm and relaxing tone Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention at the moment as the events are unfolding to make a correct clinical judgment. What did you learn that you can apply to future patients you care for? Reflect on your current strengths and weaknesses this case study identified. What is your plan to make any weakness a future strength? What Did You Learn? What did you do well in this case study? How to recognize critical lab on prenatal screen and how to treat infectious diseases during pregnancy Prioritize treating the infection to prevent preterm birth What could have been done better? What is your plan to make any weakness a future strength? I could have been more knowledgeable about the side effects of antibiotics during pregnancy Always educate my patient about the side effects and review my nursing drug book for up-to-date dat [Show More]

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