Antepartum Unfolding Clinical Reasoning Case Study

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Antepartum Care UNFOLDING Reasoning Anne Jones, 17 years old Primary Concept Reproduction Interrelated Concepts (In order of emphasis) 1. Nutrition 2. Patient Education 3. Stress 4. Coping ... 5. Clinical Judgment 6. Communication 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%  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: 17-year-old Caucasian teenager, missed two periods, breasts being tender, swollen, frequent urination, and nausea in the morning, urine pregnancy test is positive, The client is 17 years old and pregnant, which explains clinical symptoms. RELEVANT Data from Social History: Clinical Significance: : 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, broke up last week with her boyfriend, wants to keep the baby but has not told her parents. The client may not be getting all the nutrients she needs let alone the nutrients to be pregnant with a child, the mother currently does not have support from the father or her parents. She is underage and may need resources and/or assisstance thoughout her pregnancy. 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: 125/80 blood pressure tender breasts slightly elevated blood pressure just something to keep an eye on and education for the patient on her tender breasts and why that is happening. 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: appears to be slightly nervous, no appetite. BMI 18 slight bleeding at gum lines Conjunctiva of eyelids; appears pale Vagina and cervix deep purple in color slightly nervous and being 17 and pregnant with no current support system indicates to me that I need to also evaluate how she is doing mentally, talk to her build a good repor while supporting her decisions and educating her on different outcomes. Poor appetite, BMI of 18, weightloss of 5 lbs, slight bleeding of the gum lines, eyelids are pale, all indicate poor nutrition and the need for educaiton on nutrition and how important it is as well as supplements she may need. bleeding gums can also indicate the mothers hygeine habits or anemia. deep purple color is also called chadwick's sign and is an early indication of pregnancy. Lab Results: Prenatal Panel Hemoglobin RPR/VDRL HBsAG Blood type Rubella HCG ELISA Current: 11.0 mg/dL Negative Negative B- Non- immune 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: low hemoglobin low hemoglobin can indicate anemia paired with the these are the first lab non-immune to poor nutrition. values that i am seeing rubella non immune to rubella would mean that she is not up for her so i am not able HCG 20,700 to date on this vaccines and can mean that she is not to tell if they are vaccinated for other diseases as well. improving, worsening, or HCG is low. below 5 is negative for pregnancy and if she is stable. above 25 is positive for pregnancy, anything in between is a gray area and she may need retested. 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: positive for chlamydia a mother with chlamydia can pass the infection along to the baby during delivery as well as can have complicaitons during the pregnancy. 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: indicates anemia teach the client about foods that are high in iron and even get her a supplement for iron. Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: Chlamydia Gonorrhea POSITIVE Critical Value: a mother with chlamydia can pass the infection along to the baby during delivery as well as can have complicaitons during the pregnancy. azithromycin can be used to treat chlamydia during pregnancy. as well as educating the mother about the risks of the infection and safe sexual practices. 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: the client is miscarriage, premature birth, low birth weight, gastroschisis can be education on undernouris caused by a mother who has a low BMI during pregnancy. premature nutrition hed and delivery and low birthweight can be caused by anemia. when you are has iron iron deficient your body will not be able to carry adequate amounts of deficiency oxygen to your tissues. Mild iron anemia during pregnancy can be anemia expected because of increased blood volume. The mother needs to have adequate nutrients from foods to help the baby grow and develope in the womb. 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: education on proper nutrition during pregnancy to help the client gain weight and have a healthy pregnancy they must have the proper nutrients like protein rich foods, fresh fruits and veggies and adequate hydration. the client will report or even keep a food diary that has nutrient rich foods listed. 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: digestive system nutritional assessment 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: miscarriage Nursing Interventions to PREVENT this Complication: Assessments to Identify Problem EARLY: Nursing Interventions to Rescue: iron supplements and education on foods that are high in nutrients and iron abdomenal pain, spotting or bleeding, pain in the lower back. their are no interventions that can be done to stop a miscarriage from happening but she can be assessed to ensure that her anemia is getting better. 5. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity/Basic Care and Comfort) Psychosocial PRIORITIES: support groups, resources for young mothers, providing emotinoal support and listening PRIORITY Nursing Interventions: Rationale: Expected Outcome: CARE/COMFORT: Caring/compassion as a nurse Physical comfort measures providing resources like support groups for young mothers, thinking of ways to tell her parents and/or the boyfriend. listening and using touch and therapeutic communication as well as assessing ones own biases and refraining from judgment. privacy, touch, a blanket while waiting for the doctor, the client will feel less nervous about the pregnancy and will hopefully develop a support group to help her through this scary as well as exciting time. EMOTIONAL (How to develop a therapeutic relationship): Discuss the following principles needed as conditions essential for a therapeutic relationship: the client will talk to the nurse about things she is worried about and even trust in the nurse to help her develop some action plans for gaining support. • Rapport • Trust • Respect • Genuineness • Empathy Lack of support system Unplanned pregnancy it is important to show and use therapeutic communication techniques with the client, building a repport with the client will help her trust you and tell you anything that may be uncomfortable as well as ease her nerves about the unexpected pregnancy. Although for some people a young teen pregnancy is seen as a bad thing you need to check your own biases and opinions as well as making sure they do not become apparent to the client. having empathy, listening, educating, and just leding yourself to her for a short amount of time can really help the client get through this time in her life. it will also show that she has support from you the nurse to chose whichever option she wants. SPIRITUAL: it is important to gauge the clients spritual needs as well as her physical needs. using a spritual assessment tool can help the nurse to plan holistic care for the client. CULTURAL Considerations (IF APPLICABLE) culture can a play a critical role in the support the client will have in the decision to keep the baby. although I dont have enough information to gauge the culture the client has some parents who find out their children are pregnant kick them out of the house potentially causing complications for the mother and the unborn baby TWELVE-WEEKS LATER… RELEVANT Data: Clinical Significance: She has gained 10 lbs. She has told her parents, and they are supportive boyfriend has no interest gaining 10 pounds is good because she was underweight before and has shown that she may be implementing the education that was taught to her about the nutrients she needs especially while pregnant. the parents being supportive is good as well because she now has a support group and people that can help her through the pregnancy. although the boyfriend is uninterested which can make it a bit harder for the mother. 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- Non- immune 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: RELEVANT Assessment Data: Clinical Significance: slight bleeding at gum lines Conjunctiva of eyelids appear pale this indicates that she is still anemic RELEVANT Lab Data: Clinical Significance: even lower hemoglobin her anemia is worse than when she first came in for an appointment. i am unsure as to whether slight anemia can be 10.1 mg/dL. but the iron supplements and better nutrients should have made it better maybe? 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: she has gained weight which is a good sign, her parents approve and she seems less nervous than before. but she still has anemia and it is even worse than the first time she came in. I am actually unsure of what to do at this point. I am having touble finding what to do on the interent. I am unsure as to whether you can prescribe a maybe larger dose of iron? or if this is just the normal slight anemia that can be seen with pregnancy. 3. Based on your current evaluation, what are your CURRENT nursing priorities and plan of care? (Management of Care) CURRENT Nursing PRIORITY: anemia PRIORITY Nursing Interventions: Rationale: Expected Outcome: education on the effects that low iron can have on the child and the need to take the supplements and eat foods that are rich in iron In expecting mothers with anemia that baby can be born with a low birth weight or even prematurely. the mother will take steps to help raise her iron levels 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: nutriton and the importance for iron it is important that the client has the information she needs to be able to take care of herself and the unborn child. to know what could potentially happen if she doesnt focus on the priority problem. this gives her the choice and the autonomy to make informed decisions 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: i would guess that the patient has a olarge mix of emotions going on. back and fourth between really excited to have a baby and scared to take care of them. how she is going to support them, finish school, parent and provide for the baby by herself and with her parents as well as very excited because this is a major life moment. ask her how she is feeling about having the child, I may avoid asking harsh questions like how she is going to provide for them and such because they can sound judgmental. use silence and open ended questions to encourage her to open up to you as well as providing resources she can use when the child is born. 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? honestly it never really occured to me that being underweight and pregnant can be as much as a problem as being overweight and pregnant. so it was really interesting to have that take on the subject. when it came to how to connect, establish a relationship and engage with the client I knew what to do. talking and connecting with a client is a strong quality for me. as well as this case study reminded me how important it is to remove your own opinions and sterotypes from a situation and just be a compassionate human being. What could have been done better? What is your plan to make any weakness a future strength? unfortuantly i havent had any lecture yet so this case study was a little like a shot in the dark for me. I have no idea what a normal low hemoglobin would look like in someone who is pregnant. I also thought that chlamydia would be the primary problem but it was actually the nutrition. learn from lecture. My plan is right now to learn as much from the one clinical rotation and lecture as much as possible because these 7 weeks are the only time I am going to have to learn about these things before I graduate. [Show More]

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