Case Study of Medical Surgical Nursing

Chapter 1 Sarah is 19-year-old G1P0 at 36 weeks’ gestation. Sarah has been followed weekly in the clinic for mild–moderate preeclampsia. At her clinic appointment today, Sarah’s blood pressure reading was 188/104. She is admitted to the antepartum unit for management of her worsening preeclampsia. You perform her admission assessment and note that her reflexes are brisk, her heart rate is 94, she complains of having an intense headache, and is seeing spots before her eyes. You perform an abdominal assessment and note that she has significant epigastric tenderness. a. Develop a plan of care for the woman experiencing preeclampsia and/or eclampsia Plan of care for the woman experiencing preeclampsia If it is mild preeclampsia the condition is monitored and treated with medication to prevent it from turning into eclampsia. Medications and monitoring will help keep blood pressure within a safer range until the baby is mature enough to deliver.. Preeclampsia and eclampsia affect the placenta, which is the organ that delivers oxygen and nutrients from the mother’s blood to the fetus. When high blood pressure reduces blood flow through the vessels, the placenta may be unable to function properly. This may result in baby being born with a low birth weight or other health problems. Treatment aspirin calcium supplementation Exercise during pregnancy may also be useful. Antihypertensives to low BP such as hydralazine sedative complete bed rest Plan of care for the woman experiencing eclampsia In severe eclampsia delivering the baby and placenta are the recommended treatment .Problems with the placenta often require preterm delivery for the health and safety of the baby. In rare cases, these conditions cause stillbirth. Medications to prevent seizures, called anticonvulsants drugs may be necessary. Medication to lower blood pressure if high blood pressure . Steroids, are given to help baby’s lungs mature prior to delivery. Intravenous or intramuscular magnesium sulfate improves outcomes in those with eclampsia and is generally safe.Breathing may need to be supported.] Blood pressure medications such as hydralazine and emergency delivery of the baby either vaginally or by cesarean section. b. Develop a plan of care for a woman experiencing HELLP syndrome. HELLP syndrome is a life-threatening pregnancy complication usually considered to be a variant of preeclampsia. Both conditions usually occur during the later stages of pregnancy, or sometimes after childbirth. It means H (hemolysis, which is the breaking down of red blood cells) EL (elevated liver enzymes) LP (low platelet count) The mortality rate of HELLP syndrome has been reported to be as high as 30%. That's why it's critical for expecting mothers to be aware of the condition and its symptoms so they can receive early diagnosis and treatment. Most often, the definitive treatment for women with HELLP Syndrome is the delivery of their baby. During pregnancy, many women suffering from HELLP syndrome require a transfusion of some form of blood product (red cells, platelets, plasma). Corticosteroids can be used in early pregnancy to help the baby's lungs mature. Chapter 2 Nikki is a 17-year-old G1P0 at 33 weeks’ gestation. Nikki comes to the clinic today for her prenatal visit and you notice that her hair and clothing have the distinct odor of marijuana and tobacco smoke. You directly ask Nikki if she has been taking any other drugs besides marijuana. Nikki is surprised by the question and denies it. When you explain that you can smell it in her hair and on her clothing, she starts to cry and says, “Please don’t take my baby away from me.” After reassurance, Nikki further admits to sporadic binge alcohol consumption and smoking “pot” and cigarettes. She relates that she also consumes four to five caffeinated beverages per day. a. Describe how cigarette smoking, marijuana use, binge alcohol consumption, and excessive caffeine intake can affect Nikki’s pregnancy. Cigarette Smoking: Vasoconstriction, reduced uteroplacental blood flow, decreased birthweight, abortion, prematurity, abruptio placentae and fetal demise. Marijuana Use: Anemia, inadequate weight gain, “amotivational syndrome,” hyperactive startle reflex, newborn tremors, Intrauterine growth restriction(IUGR). More research needs to be conducted to better understand the effects of marijuana on pregnancy. Binge Alcohol Consumption: Spontaneous abortion, inadequate weight gain, IUGR, FASD, the leading cause of intellectual disability. Based on the best research available alcohol is known to have these effects during pregnancy. Caffeine Intake: Vasoconstriction and mild diuresis in mother, fetal stimulation but teratogenic effects not documented via research. Although there is not much research on caffeine’s effect on pregnancy a prudent nurse would advise Nikki to limit her caffeine intake. Excessive caffeine intake is associated with increased demand on the heart causing HTN, tachycardia, dysrhythmias, coronary artery spasm and sudden cardiac death. I would be better for Nikki and subsequently her fetus to reduce her caffeine intake. b. What possible affects are there to Nikki’s baby from the maternal ingestion of these substances? Intake increases the risk of alcohol related birth defects, including growth deficiencies, facial abnormalities, CNS impairment, behavioral disorders and intellectual development. No amount of alcohol is considered safe during pregnancy. Damage to the fetus can occur at any stage of pregnancy, even before a woman knows she is pregnant. Cognitive defects and behavioral problems resulting from prenatal exposure are lifelong. Alcohol related birth defects are completely preventable. Smoking has been considered an important risk factor for low birth weight, SIDS, cleft palate, clubfoot, asthma, middle ear infections, altered brain stem development and cerebral palsy, cognitive deficits especially in language, reading and vocabulary. Research has also reported that behavior problems such as increased activity, inattention, impulsivity, opposition and aggression in child with mothers who smoked during their pregnancy. Although marijuana is not considered a teratogen, many newborns display altered responses to visual stimuli, increased tremulousness and a high-pitched cry, which may indicate CNS problems. It is also important to note that there is a strong correlation between use of marijuana and use of alcohol and cigarettes. The possible effects of caffeine on Nikki’s baby are not known due to lack of research, but currently with the information available birth defects have not been linked to caffeine consumption. c. Describe the nursing care you would provide for Nikki. Nikki is a young and is need of a thorough assessment and education regarding the health of herself and her unborn baby. Assessment: 1. Have you ever used recreational drugs? 2. Have you ever taken a prescription drug other than as intended? 3. What are your feelings about drug use during pregnancy? 4. How often do you smoke cigarettes? How many per day? d. 5. How often do you drink alcohol? e. RAFFT questionare f. R: Do you drink or take drugs to relax, improve your self-image, or to fit in? g. A: Do you ever drink or take drugs while alone? h. F: Do you have any close friends who drink or take drugs? i. F: Does a close family member have a problem with alcohol or drugs? T: Have you ever gotten into trouble from drinking or taking drugs? It is important to do a drug screen if the initial assessment indications substance abuse. If the drug screen is positive, use this time to educate Nikki and discuss the effects of prenatal exposure to substances. Having a non-judgmental approach is key to successful communication and treatment for Nikki and her fetus. I would refer Nikki to counseling and establish such a rapport that would foster honest and open communication. When counseling Nikki I would be sure to include, interventions to improve mother-child attachment and improve parenting, psychosocial support if treatment is needed to reduce Nikki’s substance abuse, referral to outreach programs to improve access to treatment facilities, hazardous legal substances to avoid during pregnancy, prioritizing follow up of child, more frequent prenatal visits to monitor fetal well-being, maternal and fetal benefits of remaining drug free, communicate with cultural sensitivity and identification of coping skills, support systems and vocational assistance. j. I believe that is also important to recognize Nikki’s adolescence as a factor when providing care for Nikki. While educating Nikki on the effects of substance abuse on her pregnancy and fetus, teaching should also include pregnancy prevention. This would include: High risk behaviors that lead to pregnancy; involvement in programs that promote postponing sexual involvement; planning or goal setting to visualize their future in terms of career, college, travel and education; choice of abstinence; discussions about sexuality with a wiser adult; protection against STIs and pregnancy if they choose to remain sexually active; critical observation and review of peers and friends to make sure they are creating the right atmosphere for friendship; empowerment to make choices that will shape their life for years to come, including getting control of their own lives now; appropriate use of recreational time such as sports, drama, volunteer work, music, jobs, church activities and school clubs. Chapter 3 Laura is a 26-year-old G2P1 who had a cesarean delivery for fetal distress with her first pregnancy. Laura is now struggling with deciding between a repeat cesarean delivery or attempting a VBAC. a. In order to ensure that Laura has the facts to assist her in her decision, explain the risks of a repeat cesarean delivery. The risk factors of a repeated cesarean delivery includes; infections, hemorrhage ,injury to other organs, formation of adhesions, longer stay in the hospital, risk of maternal mortality and also more reactions to medications b. Laura can’t understand why more women don’t want to try a VBAC delivery. Discuss the possible reasons for this. The reasons many women prefer the CS to Vaginal birth includes; Fear of the labor pains i.e. she might not want to experience labor pains for prolonged hours, Myths and misconceptions about vaginal delivery, Fear of injury, The would like to minimize the risk of complications that are involved in the vagina deliver and also misconceptions that the vagina will not return to its normal size. c. Describe the management of care for a woman attempting a VBAC delivery. Before delivery; the patient’s vitals i.e. blood pressure, temperature, pulse, respiration rate should be carried out frequently. The fetal heartbeat should be monitored regularly and massaging of the abdomen should be done. Health education on pain management whereby she should rub her lower back at the sacrum region and this helps in reducing the pain as a result of labor. The patient should be told what to do and what not to do during delivery time to make it easier for the nurse during childbirth. During deliver; ensure that the mother is lying at her back and all equipments set to minimize the risk of infection, Monitor the fetal heart rate, Deliver the baby and then deliver the placenta as your assistant cares for the baby by measuring the birth weight and ensuring that the baby is kept warm. After birth; Health education in the right breast feeding technique, monitoring the mother blood pressure, monitoring for infections and also postpartum hemorrhage and the give the baby to the mother for breast feeding. After monitoring of the mother for around five hours transfer her together with the baby to the postnatal ward Chapter 4 Amy calls the office 3 days after delivering a healthy baby girl and tells you she is passing small clots and feels like her bleeding is heavier than it should be. You advise Amy to come into the clinic to be checked. a. What are the “four Ts” that need to be assessed in a possible case of postpartum hemorrhage? Four T’s; the Tone, Tissue i.e. retained blood clots or tissues, Trauma i.e. any injury and also Thrombin. b. Amy also tearfully tells you that she is experiencing anxiety and feelings of being overwhelmed. What is she experiencing, and what education are you going to provide? Health Education; maintain personal hygiene to prevent infections, takin a balanced nutritious diet, returning back to the hospital for checkup, reassuring her that she will be okay this helps in relieving her the anxiety and also teach her on self-lower abdomen massage. Alyssa, age 26, had a cesarean delivery 7 days ago and is breast-feeding her baby. She calls the office today and reports that she has a temperature of 102. Given the limited information you have, describe the four most likely types of infection Alyssa may have contracted. a. What additional questions do you want to ask her to try to ascertain the cause of her fever? a. Mastitis which refers to the infections on the breast b. Urinary tract infections whereby there is pain during urination or increased urgency and also frequency of urination c. Endometritis which is referred to as the infection of the uterine layer called endometrium. d. Infection at the incision site as a result of entry of microorganisms which leads to formation of a pus a sign of an infection The presence of a pus from the incision, the presence of a white discharge from the vagina, the smell of the discharge, and also the color of the discharge whether its white or yellow? b. Describe the care required to treat each of these infections. Urinary tract infections; administer antibiotics, administer analgesics to minimize the pain from the infection of the tract. Mastitis; Administer antibiotics, maintain personal hygiene Infection at the incision; Debridement of the non-viable tissues, cleaning of the wound with normal saline e and hydrogen peroxide, dressing of the wound, enhance proper and a balanced diet with more protein to facilitate healing. Endometritis; administer antibiotics, analgesics an also ant inflammatory drugs. Educate on patient teaching.