Transcript File - Julianne Tamoney`s E

OB Case Study
# Five
Casey Stevens
Julianne Tamoney
Background Information
Emily is a 27 year old G 3 P 2002 at
35 weeks gestation who has just
arrived in L&D triage after calling her
obstetrician because she has not felt
her baby move today.
Emily’s Scenario
Diagnoses:
Pregnancy at 35 weeks gestation
History:
Previous pregnancies full term
with no complications.
No significant medical history
Data:
Height: 5’5”
Weight: 161 (25 lb. pregnancy
weight gain)
Lab:
Prenatal labs all WNL
Antepartum Testing:
Sonogram at 18 weeks normal,
indicated probable female fetus
Medications:
Prenatal vitamin once daily
Diet:
Regular
Admission VS:
Blood Pressure: 154/90
Temperature: 98.4 degrees F
Heart Rate: 88
Respirations: 22
Other:
Husband on his way from work, 2
sons ages 3 & 5 with grandparents
Patient tearful, worried about
“losing my little girl”
Pertinent Assessment Data
Subjective:
Mother stated that she has not felt her baby move today.
Objective:
Abdomen soft, no contractions or fetal movement
palpated
No abnormal findings on physical assessment
Maternal pulse and heart rate heard on fetal monitor
are synchronous
Electronic Fetal Monitor
Additional Information Needed
Questions to ask Emily:
When was the last time you felt
your baby move?
Have you been counting fetal
movements at the same time
everyday?
If so, what was the normal
daily count and the quality
of movement.
Have you tried any
interventions like eating,
drinking, and resting to
promote fetal activity?
Have you experienced any of
these symptoms:
Fluid leaking
Vaginal bleeding
Abdominal Pain
Fever/Chills
Dizziness
Blurred Vision
Persistent Vomiting
Edema
Muscular irritability or
convulsions
Decreased urinary
frequency
Painful urination
Nursing Actions
Reassess maternal vitals
Reassess fetal heart rate by using an
electronic fetal monitoring
Stat call to the physician
We want the physician to see this patient
stat because the patient could die of DIC
Next Step: Reporting to
the physician
Situation:
A 27 year old female came into triage
because she has not detected any fetal
movement today. She is suspected to be 35
weeks gestation with a G3 P2002.
Background:
The patient has had no complications with
previous pregnancies.
The patient’s prenatal labs came back all
within normal limits.
The patient’s sonogram at 18 weeks was
documented as normal.
The patient is on a regular diet and taking
prenatal vitamins once daily.
Assessment:
Admission vital signs:
BP 154/90
T – 98.4 degrees F
P – 88
R – 22
Abdomen soft, no contractions or fetal
movement palpated
No abnormal findings on physical
assessment
Maternal pulse and heart rate heard on
fetal monitor are synchronous
Recommendation:
We would recommend repositioning
the patient on her left side,
administering an IV bolus, and
administering 100 % oxygen.
We would also recommend an
ultrasound examination of the fetus.
We suspect fetal death due to an
absence of fetal movement and heart
beat.
Physician Orders and
Interventions
Continuous maternal and fetal monitoring.
Assess and document the patients condition every 15 minutes.
Verbal order for a stat ultrasonography.
The highest priority in the situation would be to get the ultrasound
results
Contact if patient’s status changes
Results
The results from the ultrasound have confirmed fetal
death.
The family have been informed by the physician and
have been given instructions regarding delivery.
Nurse’s role:
Stay with family during birth.
Respect their wishes in regards to seeing the
infant.
Allow the family the amount of time desired with
infants.
Potential Problems
Problems
Still born
Disseminated intravascular
coagulation (DIC)
To prevent this from occurring
be prepared to have the
physician induce labor or
preform a cesarean delivery.
Possible fragile emotional state
due to loss of fetus.
Be prepared to contact chaplain
Infection from retained
products.
People Involved
Patient’s physician or
certified midwife
Anesthesiologist
Chaplain
Nurse
Medical examiner
Patient Teaching
Grief/Support information is given to mother/family.
Offer to call patient’s own clergy or Pastoral care.
Inform patient of her options:
To see and hold the infant, discuss demise appearance prior to
mother holding.
To bathe and dress the infant.
Give the parents time alone with the infant.
Choice of room change after delivery or unit transfer if patient
request.
Discuss creating memories
Footprints, photos, blanket, and clothes.
Documentation
Nurse’s interventions
Verbal orders given by physician
Maternal vital signs and status q15
EFM readings
Time delivered
If born dead or alive
Presence of anomalies
Gestation
NCLEX Question
A mother is pregnant again after a miscarriage. Which
of the following nursing interventions will best assist in
alleviating anxiety related to the prior loss?
A. Referring the mother to a genetics counselor
B. Providing the contact information for a perinatal loss
support group
C. Explaining all tests and procedures
D. Performing an early ultrasound
NCLEX Question
A mother is pregnant again after a miscarriage. Which
of the following nursing interventions will best assist in
alleviating anxiety related to the prior loss?
A. Referring the mother to a genetics counselor
B. Providing the contact information for a perinatal loss
support group
C. Explaining all tests and procedures
D. Performing an early ultrasound
NCLEX Question
A client at 19 weeks gestation complains of vaginal
spotting and cramping. Which of the following signs
indicates an intrauterine fetal demise? (Select all that
apply)
A. No detected fetal cardiac activity
B. Positive Spalding’s sign
C. Increased estrogen levels
D. Decreased estrogen levels
NCLEX
Question
A client at 19 weeks gestation complains of vaginal
spotting and cramping. Which of the following signs
indicates an intrauterine fetal demise? (Select all that
apply)
A. No detected fetal cardiac activity
B. Positive Spalding’s sign
C. Increased estrogen levels
D. Decreased estrogen levels
References
Bhatia, v., Grivell, R., Wong, L. (2012). Regimens of fetal surveillance for impaired fetal growth. The Cochrane Library. Retrieved from
http://onlinelibrary.wiley.com.ezproxy.hsc.usf.edu/doi/10.1002/14651858.CD007113.pub3/full
Black, B. (2011). Interconception care for couples after perinatal loss: A comprehensive review of the literature. The Journal of Perinatal
& Neonatal Nursing, 25(1), 44-51. Retrieved from http://ovidsp.tx.ovid.com.ezproxy.lib.usf.edu/sp-3.11.0a/ovidweb.cgi?
T=JS&PAGE=fulltext&D=ovft&AN=00005237-201101000-00012&NEWS=N&CSC=Y&CHANNEL=PubMed
Fordyce, L. (2013). Accounting for fetal death: Vital statistics and the medication of pregnancy in the United States. Social Science &
Medicine, 92, 124-131. Retrieved from http://www.sciencedirect.com.ezproxy.hsc.usf.edu/science/article/pii/
S0277953613003080
Hofmeyr, G., Novikova, N. (2012). Management of reported decreased fetal movements for improving pregnancy outcomes. The Cochrane
Library. Retrieved from http://onlinelibrary.wiley.com.ezproxy.lib.usf.edu/doi/10.1002/14651858.CD009148.pub2/
abstract;jsessionid=D1F7B8690E5EC6D648D1C3E85D0719C8.f02t04
Lexicomp. (2013). Neonatal loss after 20 weeks. Retrieved from http://online.lexi.com.ezproxy.hsc.usf.edu/lco/action/doc/retrieve/
docid/
disandproc/3558379#treatment