Transcript Unfolding Case Study

PERINATAL
UNFOLDING CASE STUDY
1
Tanya Carmichael, MSN, RNC
Christina Harkins, MSN, RNC
Mary Lou Gies, Ed.D, RN
La Salle University
INITIAL PRENATAL
VISIT

You are a registered nurse (RN) working in a
Women’s Health Clinic. Mary Johnson, 38
years old, presents to the prenatal clinic after
missing her last 2 menstrual cycles. Her home
pregnancy test was positive. An ultrasound
at the clinic confirms pregnancy. Gestational
age is calculated to be 10 weeks. An initial
assessment of Ms. Johnson’s medical and
obstetrical history follows.
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HISTORY
Obstetric/Gynecologic (OB/GYN) history (hx):
Uncomplicated spontaneous vaginal delivery
(SVD) at 38.2 weeks (5 years ago); Cesarean
section (C/S) x 1 at 37.5 weeks for nonreassuring fetal heart tones (FHT) (3 years
ago); abnormal Papanicolaou (PAP) smear
x 1, + human papilloma virus (HPV),
colposcopy within normal limits (WNL);
Chlamydia with treatment (7 years ago)
 Medical hx: Chronic hypertension (HTN) x 5
years; asthma  no intubations or
hospitalizations; hx of breast biopsy, benign
(2 years ago)
 Allergies: Penicillin

3
HISTORY



Social hx:
 (+) tobacco, “occasional” per patient (pt), <5
per/day currently, has smoked “off and on”
for 15 years
 (+) cocaine use, states she has not used any
cocaine/drugs for > 1 year; (-) alcohol use
 Abusive partner with first pregnancy, states
she has a new partner x 4 years
 Depression, currently not taking meds for
treatment (tx)
Medications: Prenatal vitamins; Labetalol
200mg BID; Albuterol inhaler as needed (prn)
Family hx: Insulin-dependent diabetes mellitus
(mother); HTN and heart disease (father); lung
cancer (CA) (maternal grandmother, deceased)
4
What should the nurse consider
related to caring for a patient
with a history of domestic abuse,
drug use, sexually transmitted
diseases and depression?
5
Professional nurses should be
aware of attitudes, values and
beliefs that they hold related to
patients from different social
backgrounds so that care is not
affected negatively.
QSEN: KSA (next slide)
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QSEN KSA:
PATIENT CENTERED CARE



KNOWLEDGE: Review patient support
system and resources
SKILL: Refer patient to appropriate
resources r/t domestic abuse and addiction
as indicated
ATTITUDE: Recognize personally held
attitudes about working with patients from
different ethnic, cultural and social
backgrounds; willingly support patientcentered care for individuals and groups
whose values differ from own
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INITIAL
PRENATAL VISIT



Vital Signs (VS):
 Temp 98.10 F, RR 20, HR 86, BP 142/79
WHAT LABORATORY AND ASSESSMENT
DATA SHOULD BE COLLECTED DURING
THIS VISIT?
AFTER CONSIDERING THE
INFORMATION PROVIDED, WHAT OTHER
ASSESSMENTS AND ISSUES NEED TO BE
ADDRESSED DURING THIS PRENATAL
VISIT?
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WHAT LABORATORY AND ASSESSMENT DATA
SHOULD BE COLLECTED DURING THIS VISIT?
LAB DATA:









Complete blood count (CBC)
Blood type and Rh
Rh antibody screen
Gonorrhea and Chlamydia
cultures
Serology - Syphilis (RPR or
VDRL)
Rubella
Hepatitis B surface antigen
HIV testing (offer test;
provide pretest counseling)
Urine drug screen (UDS)
ASSESSMENT DATA:




Baseline VS: pay special
attention to BP – pt with
hx of HTN
Weight: 150 lbs
FHR (from doptone or
ultrasound): 145
Baseline review of
systems assessment
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LABORATORY VALUES
What is the significance of these lab values?
Determination
Patient Result
Reference / Normal
Hemoglobin (Hgb)
12.7 g/dL
Female: 12-16 g/dL
Hematocrit (Hct)
37%
Female: 40%-48%
White Blood Cell Count (WBC)
9,000
5000-10,000/mm³
Blood type and Rh
A-
N/A
Rh antibody screen
+
_
Gonorrhea & Chlamydia cultures
_
_
Serology (RPR, VDRL)
_
_
Rubella
Immune
Immune
HIV
_
_
UDS
_
_
Hepatitis B surface antigen
_
_
Reference: Pagana, K.D, & Pagana, T.J. (2003) Diagnostic & Laboratory Test Reference,, 6th Ed. Mosby, Inc.: St. Louis, MO
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AFTER CONSIDERING THE INFORMATION
PROVIDED, WHAT OTHER ASSESSMENTS AND
ISSUES NEED TO BE ADDRESSED DURING THIS
PRENATAL VISIT?


Safety Screening: Pt has a history of an abusive
partner, depression and drug use. Psychosocial
assessment (including domestic violence) and
depression / suicide risk would be important
during this first visit.
Smoking history: council pt. on smoking
cessation.
QSEN KSA: Safety

Skill: Use appropriate strategies, such as Psychosocial Screening Tool (slide
13) and Depression/Suicide Risk Assessment (slide 15):


to reduce reliance on memory when assessing the patient’s risk
to reduce risk of harm to self or others
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PSYCHOSOCIAL SCREENING TOOL
Do you have any problems (jobs, transportation, etc)
that prevent you from keeping your health care
appointments?
Do you feel unsafe where you live?
During the past year, has anyone hit you or tried to
hurt you?
Do you or any members of your household go to bed
hungry?
How do your rate your current stress level- low or high?
How many times have you moved in the past 12
months?
In the past 2 months, have you used any form of
tobacco, drugs, or alcohol?
If you could change the timing of this pregnancy, would
you want it earlier, later, not at all, or no change?
Adapted from: ACOG Committee Opinion, No. 343. (August, 2006). Psychosocial risk
factors: Perinatal screening and intervention. Obstetrics and Gynecology, 108(2), 469-477.
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DEPRESSION/SUICIDE RISK
ASSESSMENT

As the RN working with Ms. Johnson how often
would you assess her psychosocial status, level
of depression and risk for suicide?


According to ACOG, screening should be performed
AT LEAST once each trimester. Problems may arise
during the pregnancy that were not present at the
initial visit.
What questions would you ask her?
13
ACOG Committee Opinion, No. 343. (August, 2006). Psychosocial risk factors: Perinatal
screening and intervention. Obstetrics and Gynecology, 108(2), 469-477.
DEPRESSION / SUICIDE RISK
ASSESSMENT
 Depression


Over the past 2 weeks, have you ever felt
down, depressed, or hopeless?
Over the past 2 weeks, have you felt little
interest or pleasure in daily activities?
 Suicide



Risk Questions:
Risk Questions:
Do you have thoughts of injuring
yourself?
Do you have thoughts of killing yourself?
(If yes) Do you have a plan?
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DEPRESSION
 Untreated
depression has been
associated with unfavorable
health behaviors in pregnancy
and may contribute to:
Fetal growth restriction
 Preterm delivery
 Placental abruption
 Newborn irritability

15
ACOG Committee Opinion, No. 343. (August, 2006). Psychosocial risk factors:
Perinatal screening and intervention. Obstetrics and Gynecology, 108(2), 469-477.
RISK FACTORS
 Ms.
Johnson is at greater risk for
which pregnancy complications
as a result of her medical and
social history?
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RISK FOR PREGNANCY
COMPLICATIONS
 Ms
Johnson’s medical and social
history puts her at higher risk for:






Preeclampsia
Low birth weight infant
Preterm labor &/or preterm birth
Intrauterine growth restriction
Spontaneous abortion
Placental abruption
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TEACHING
What
are the priority
teaching points to discuss
with Ms. Johnson before she
leaves the clinic today?
QSEN KSA: Patient Centered Care

Knowledge: Integrate understanding of multiple dimensions of patientcentered care, i.e. information, communication, and education
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TEACHING
 Signs/symptoms
of preeclampsia,
preterm labor and abruption

Information and resources for support
related to (r/t) safety at home,
depression, suicide, drug use or any
other concerns about caring for her self
and her family
 Stress
importance of consistent prenatal
care throughout the pregnancy
 Smoking

Cessation
Provide measures to support quitting
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Signs & Symptoms

Preeclampsia








Continuous H/A
Elevated B/P
Edema
Epigastric pain
Shortness of breath
Dizziness
Decreased urinary output
Visual disturbances
(blurred vision or spots)

Preterm Labor








Cramping
Pelvic pressure
Vaginal discomfort
Increased vaginal
discharge
Loss of fluid
Vaginal bleeding
Feeling “not right”
Abruption




Vaginal bleeding
Abdominal tenderness
Low back pain
Cramping
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
Ms. Johnson has been able to come to all
but one of her scheduled prenatal visits.
She has been taking her blood pressure
regularly at home and reports a range of
138-165/72-90. She has denied symptoms of
headache (HA), epigastric pain, visual
disturbances, shortness of breath, dizziness.
Urine dipstick at clinic visits has shown 0 to
trace protein. Her asthma has been stable,
with occasional use of her inhaler. She
denies use of cocaine, other drugs, and
alcohol. She states that she is “trying to
smoke only 2-3 cigarettes / day” but
sometimes smokes up to ½ pack on stressful
days.
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TRIAGE VISIT: AFTER A FALL
 Ms.
Johnson is now 27 weeks
pregnant. She presents to the
perinatal triage unit of the hospital
reporting that she slipped and fell in
the shower.
 What are the priority nursing
assessments at this time?
QSEN KSA: Patient-Centered Care

Skill: Engage patient or designated surrogates in active partnerships that
promote health, safety, and well-being, and self care management.
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PRIORITY NURSING ASSESSMENTS
Maternal VS
 Fetal heart rate
 Contractions (ask patient and use
tocodynamometer)
 Do you feel fetal movement? How often?
 Are you having any vaginal bleeding? How many
pads have you filled in the last hour?
 Do you feel any vaginal discharge or leaking?
 Are you having any abdominal pain or
tenderness?
 Review more specific history related to fall…
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determine if related to domestic abuse

 Assessment
data:
Maternal VS: BP 154/82, HR 98, RR 20, T 98.80 F
 FHR baseline: 150 with moderate variability; +
accelerations noted; occasional variable
decelerations noted
 Occasional contractions: ~ 3-4/hour
 + fetal movement
 No vaginal bleeding or loss of fluid
 No abdominal pain or tenderness
 Pt denies HA, visual disturbances, right upper
quadrant pain; urine dipstick trace protein


Ms. Johnson denies that the fall resulted from
any form of domestic violence; states that she
does not feel unsafe in her home.
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RHOGAM
 After
2 hours of observation with no
change in pt status, the physician orders
administration of RhoGAM. Why?
 What
actions does the nurse need to take
prior to administering this medication?
QSEN KSA: Safety


Knowledge: Describe processes used in understanding causes of error and
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allocation of responsibility and accountability
Skill: Demonstrate effective use of technology and standardized practices that
support safety and quality
RHOGAM
Prevents formation of active antibodies against
Rh+ erythrocytes which may enter maternal
bloodstream during pregnancy with Rh+ fetus
 Generally given at 28 weeks. Also given with:

Bleeding or suspected hemorrhage
 Threatened abortion
 Abdominal trauma


Prior to administration:





Send current type & screen
Indirect Coombs
Explain purpose and side effects; answer pt
questions
Obtain informed consent
Verification by 2 RNs
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 Ms.
Johnson is stable at home until
30 weeks gestation. At that time she
is returns to the hospital
complaining of vague lower
abdominal pain with a gush of
vaginal bleeding ~1 ½ hours ago,
soaking 2 pads within 2 hours. The
bleeding has tapered off to spotting.
She reports + nausea and abdominal
cramping; pain 3/10.
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 External
fetal monitor (EFM) &
Tocodynamometer (TOCO) are
applied and show a FHR baseline of
150, moderate variability, occasional
accelerations, no decelerations
noted; + uterine irritability noted
with mild contractions ~ 3-4 minutes
apart
 VS: BP 168/82; HR 102; RR 20;
T 98.10 F

QSEN KSA: Informatics

Skill: Apply technology and information management tools to support
safe processes of care; Use high quality electronic sources of
healthcare information
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 What
do you suspect may be occurring?
 Based
on the initial assessment, what
are the priority nursing interventions
for Ms. Johnson?
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NURSING INTERVENTIONS FOR
PLACENTA PREVIA/ABRUPTION
 Notify
MD
 Explain situation
to pt
 ID and allergy
bands
 Continuous EFM
& TOCO
 Initiate pad count
 Urine dipstick
 Laboratory
data
Type & screen
 CBC
 Coagulation studies
 Chemistry profile

 Urine
analysis:
including UDS
 Large bore IV and
fluids
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QSEN KSA: Patient Centered Care
• Attitude: Value seeing health care situations “through patient’s eyes”
NURSING INTERVENTIONS FOR
PLACENTA PREVIA/ABRUPTION
 Assess
patient understanding of plan
of care
 Teach patient to notify RN of any
changes
 Explain procedures, answer
questions and offer reassurance
 Ensure that informed consents for
surgery and blood transfusion are on
chart
 Suggest Neonatology consult
QSEN: KSA (next slide)
31
QSEN KSA: NURSING INTERVENTIONS FOR
PLACENTA PREVIA/ABRUPTION
QSEN KSA: Patient-Centered Care
Skill: Provide patient-centered care with sensitivity &
respect for the diversity of human experience; Assess own
level of communication skill in encounters with patients
and families
 Attitude: Value active partnership with patients or
designated surrogates in planning, implementation, and
evaluation of care

QSEN KSA: Teamwork and Collaboration
Skill: Demonstrate awareness of own strengths and
limitations as a team member
 Attitude: Acknowledge own potential to contribute to
effective team functioning

QSEN KSA: Safety

Skill: Demonstrate effective use of technology and
standardized practices that support safety and quality
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 Placenta
previa ruled out per ultrasound
(us). No clots noted on u/s. Speculum exam
confirms ~10 mL blood in vault, no clots; 1
cm dilated visually. Vaginal bleeding
continues: small amounts of occasional
bright red spotting on pads. FHTs remain
reassuring.
 + UDS
 Patient admitted for high risk antepartum
surveillance
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 At
2330, the nurse notes that FHR
baseline has increased to 170 with no
accelerations, and repetitive late
decelerations. Vaginal bleeding has
increased, and patient reports sharp
abdominal pain (8/10) with uterine
tenderness on palpation. Contractions
have increased in frequency, ~ 2-3 min
apart and uterus remains firm between
contractions.
 VS:
BP 150/72 ; HR 110; RR 22; Temp
97.90F; Pulse oximeter (pox) on room
air 96%
34
WHAT ARE THE PRIORITY NURSING
INTERVENTIONS AT THIS TIME?

Notify the physician immediately

Plan for probable stat cesarean section
Call for additional help to prepare for surgery
 Intrauterine resuscitation


IVF bolus, 10L O2 via face mask, pt to left lateral
position
Frequent VS
 Insert foley catheter & complete shave prep
 Draw and send blood for type and cross-match;
ensure MD order for blood products
 Explain all interventions to patient and reasons
for moving quickly

QSEN: KSA (next slide)
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QSEN KSA: Priority Nursing
Interventions for Abruption
QSEN KSA: Safety


Skill: Demonstrate effective use of strategies to reduce risk
of harm to self and others
Attitude: Value own role in preventing errors
QSEN KSA: Teamwork and Collaboration



Knowledge: Describe own strengths, limitations & values as
a team member
Skill: Demonstrate awareness of own strengths &
limitations as a team member; assume role of team member
or leader based on the situation; initiate requests for help
when appropriate to situation; integrate contributions of
others who play a role in helping patient/family achieve
health goals
36
Attitude: Acknowledge own potential contributions to
effective team functioning
TO ENSURE MS. JOHNSON’S SAFETY IN THE
OPERATING ROOM (OR), WHAT
VERIFICATIONS MUST BE COMPLETED PRIOR
TO TRANSFER?
ID band is in place and pt is correctly
Identified by 2 identifiers
 All jewelry, clothing, metal removed
 Confirm allergies
 Verify informed consents for surgery and
blood transfusion on chart

QSEN KSA: Safety

Skill: Demonstrate effective use of strategies to reduce risk of harm to self
and others
37
 Physician
immediately notified and at
bedside; pt is 6/90/-1 on vaginal exam with
moderate bright red vaginal bleeding
 Maternal VS: BP 120/60, HR 108, RR 23,
T 99.40F, pox 100% on 10L O2; patient very
anxious
 FHTs continue to be ominous with
repetitive late decelerations
 Multidisciplinary team mobilized for stat
cesarean section
38
OPERATING ROOM

In the OR, one RN is responsible for circulating,
and you are responsible for baby care and
resuscitation, with the team from the neonatal
intensive care unit (NICU). The team from the
NICU is waiting in the OR and report is given.
After a “time out” the patient goes under
general anesthesia and the baby is born ~ 3
minutes later. Apgars were 5 at one minute, and
7 at five minutes.
QSEN KSA: Safety


Skill: Demonstrate effective use of strategies to reduce risk of harm to self
and others
Attitude: Value own role in preventing errors
39
TRANSFER TO NICU
 Prior
to transfer to the NICU,
what priority action must the
NICU nurse take?
40
TRANSFER TO NICU
 The
baby must be properly identified via 2
bands with mother’s name, baby’s date
and time of birth. Also, footprinting and
band ID number should be confirmed by
another RN and matching bands applied to
mother & significant other prior to
transfer to NICU.
QSEN KSA: Safety


Skill: Demonstrate effective use of strategies to reduce the risk of harm to self
others
Attitude: Value the contributions of standardization/reliability to safety;
appreciate the cognitive and physical limits of human performance; value own
role in preventing errors
or
41
PATIENT TRANSFER
 Ms.
Johnson is transferred from the
OR to the recovery room, and then to
the postpartum unit.
 What
should be included in the SBAR
report?
42
SBAR REPORT

Situation
Mom: Name, room #, physician,
 time/type of delivery, assistive instruments
 Infant: gestational age, sex, weight, apgars, feeding
type


Background


Patient prenatal history and history since admission
Assessment
Mom: vital signs, BUBBLEHEP findings
 Infant: vital signs, dextrostix, abnormal assessment
findings


Recommendations

Newborn initial eye care, Vitamin K
QSEN: KSA (next 2 slides)
43
QSEN: PATIENT TRANSFER
QSEN KSA: Teamwork and Collaboration

Skill: Assume role of team member/leader based on
situation; function competently within own scope of
practice as member of health care team; integrate
contributions of others who play a role in helping
patient/family achieve health goals; follow
communication practices that minimize risks
associated with handoffs among providers and across
transitions
QSEN KSA: Patient-centered Care

Knowledge: Integrate understanding of multiple
dimensions of patient centered care: information,
communication, and education
44
QSEN: PATIENT TRANSFER
 QSEN


Skill: Use appropriate strategies to reduce
reliance on memory
Attitude: Value the contributions of
standardization/reliability to safety;
appreciate the cognitive and physical limits
of human performance; value own role in
preventing errors
 QSEN

KSA: Safety
KSA: Quality Improvement
Skill: Use tools to make processes of care
explicit
45
PATIENT TRANSFER
The postpartum nurse does the initial
assessment and the patient’s condition is stable.
She tells her that her family is in the waiting
room, asking to see her. She asks her if she is
ready for visitors.
 Her family arrives and are elated about the new
addition to the family!

QSEN KSA: Teamwork & Collaboration



Knowledge: Recognize contributions of other individuals & groups in helping
patient/famlly achieve health goals.
Skill: Integrate the contributions of others who play a role in helping
patient/family achieve health goals.
Attitude: Respect the centrality of the patient/family as core members of the
health care team.
46
NURSING DIAGNOSES
AND INTERVENTIONS
 Identify
3 nursing diagnoses and 2
nursing interventions that would
apply to the patient at this time
 Identify
3 nursing diagnoses and 2
nursing interventions that would
apply to the newborn at this time
47
N-CLEX STYLE PRACTICE
QUESTION

A patient is admitted with abruptio
placentae. The nurse should assess the
patient for which of the following signs and
symptoms? (Select all that apply)
Vaginal bleeding that is concealed or
apparent
b. Abdominal pain
c. Board-like abdomen
d. Large placenta
e. Incontinence
a.
48
N-CLEX STYLE PRACTICE
QUESTION

A patient is admitted for preterm labor at
33 week’s gestation. The nurse administers
betamethasone (Celestone). What is the
purpose of giving this drug?
To stop the patient’s labor
b. To decrease the patient’s pain level
c. To promote infant surfactant production
d. To prevent a complicated delivery
a.
49