Maternal Newborn Part 4

Ms. Susie Smith Room 305 Ms. Susie Smith, 33 y/o G2P0 at 42 weeks’ gestation. She is single with a limited support system. She has just completed a Non-Stress Test (NST) which was interpreted as being Non-Reactive. Her obstetrician has now ordered an Oxytocin-Stimulated Contraction Stress Test (CST). Fetal membranes are intact. Ms. Smith also has a history of hypertension and a previous pregnancy loss at 18 weeks’ gestation. She is crying and states “I can’t lose another baby”. External tocodynamometer and fetal ultrasound transducer remain in place from the NST. Category Educational Needs Fall Risk Health change Pain level Physiological Needs Sensorium Needs Your response Increased acuity Increased acuity Increased acuity Normal acuity Increased acuity Normal acuity Explanation Status assessment reports order for additional testing procedure. Related to late stage of pregnancy and change of center of gravity. Status assessment reports post-term pregnancy with non-reactive NST. Status assessment does not indicate report of pain. Status assessment reports need for additional maternal-fetal testing. Status assessment reports no indication of altered sensorium. Physiological Description Acute Pain Anxiety Bleeding Infection, Risk Your Response Explanation False Status assessment reports no indication of pain. True Status assessment reports patient crying and expressing fear of losing a second pregnancy. False Status assessment reports no indication of bleeding. False Status assessment indicates intact membranes and no increased risk for infection. Description Nausea Risk for Impaired Fetal Gas Exchange Safety Description Deficient Knowledge Disturbed sensory perception Fall, Risk for Impaired Maternal Infant Bonding, Risk for Maternal Injury, Risk for Your Response Explanation False Status assessment reports no indication of nausea. True Status assessment indicates post-term pregnancy at 42 weeks gestation. Placental reserve can be decreased affecting its ability to oxygenate fetus. Your Response Explanation True Status assessment reports additional testing required, requires additional education. False Status assessment reports normal sensory perception. True False True Risk for Ineffective Coping True 1 Discuss with woman fears about baby health; offer reassurance. 2 2 Status assessment reports mother is post-term, changes in center of gravity and balance may increase risk for fall. Status assessment reports no indication of increased risk. Status assessment reports planned use of oxytocin, a high-alert medication requiring careful titration to prevent uterine tachysystole. Risk assessment reports minimal family support; patient visibly upset. 3 Therapeutic communication establishes a trusting nurse-patient relationship. Educate woman on oxytocin contraction stress test (CST) procedure. Have woman empty her bladder. 4 Position woman in Semi-Fowlers Education allows for planning and implementation of patient care, allays anxiety and reduces stress. Provides patient comfort during procedure. 3 Optimizes utero-placental perfusion by 4 position with left lateral tilt. 5 preventing supine hypotension secondary to vena cava compression. Ensures accurate detection and recording of uterine contractions or fetal movements. Reassess placement of tocodynamoneter and transducer. 5 Your Correct order order 1 1 Assess maternal vital signs. 2 2 Assess FHR baseline and reactivity. 3 3 Assess monitor tracing for presence of contractions, palpate uterine fundus for contractions. 4 4 Obtain IV access with #18 gauge IV catheter and begin 1000 ml Lactated Ringer’s solution at 125 ml/hour on IV pump. 5 5 Administer oxytocin intravenously through a secondary line connected to the main line at the proximal port with an IV pump; begin at 1 mu/min per healthcare provider prescription. Step Assess contraction 1 pattern and palpate uterine resting tone. 2 2 3 Validate contraction pattern per monitor tracing and determine if there is an indication to adjust oxytocin rate. Assess fetal status. Reassess maternal vital signs. Explanation Establish baseline immediately prior to initiation of oxytocin. Establish baseline fetal status immediately prior to initiation of oxytocin. Abnormal contraction patterns, including uterine tachysystole can occur with use of oxytocin. Mainline fluid infusion ensures continuous venous access if oxytocin needs to be discontinued and adequate hydration. Prevents an inadvertent bolus of oxytocin if discontinued and mainline LR is increased. Fetal status must be reassuring to increase oxytocin rate. Alteration in maternal vital signs can occur with 3 4 Increase oxytocin to 2 mu/minute per healthcare provider order. 5 Educate and reassure the client. 4 5 Your Correct order order 1 1 2 2 3 3 4 4 5 5 increasing oxytocin dosages. Assessment indicates continued upward titration of oxytocin dosage per contraction stress test protocol and healthcare provider orders. Education allows for planning and implementation of patient care. Step Palpate fundus for resting tone and contraction intensity. Collaborate with healthcare provider on CST interpretation. Explanation To determine response to oxytocin and verify intensity of contractions. Collaboration with healthcare provider regarding accurate interpretation of CST results; No late decelerations of FHR indicate negative test. Discontinue oxytocin infusion. Negative CST has been achieved with verification of results with healthcare provider. Educate client on test results. Negative CST indicative of positive fetal outcome; woman may be confused with terminology. Document assessment and Accurate documentation is done after performance of patient test results. care. 1 Using a sterile gloved hand, test fluid leaking from vagina with Nitrazine paper. 2 2 Nitrazine paper differentiates amniotic fluid (alkaline) from urine (acidic). Reapply tocodynamometer and transducer to maternal abdomen. Continued maternal/fetal assessment with spontaneous rupture of membranes and labor initiation is needed due to new onset spontaneous rupture of membranes. 3 3 4 4 5 5 Maintain IV access with Lactated ringer’s infusion. Notify healthcare provider of assessment findings and collaborate on plan of care. Reassure woman and educate on plan of care. To facilitate medication administration and labor management. Healthcare provider and nurse interpret assessment data and new findings to change plan of care and planned discharge. Client will require teaching and support due to initiation of labor and change in plan of care. Jenny Smith Room 306 Jenny Smith, 23-year-old, G2P1, estimated gestation age of 10 weeks with complaints of vaginal bleeding and abdominal cramping. No medical hx, allergic to sulfa drugs. Lab results showed a decreased serum HCG from previous result. No fetal movement seen by ultrasound and no fetal heart tones could be obtained. Pelvic exam revealed an open cervical os with blood noted. She states that her pain is abdominal cramping, rates it from a 4/10 to a 7/10 and is still having vaginal bleeding. She has pain medication prescribed q4h prn and received a dose about 1 hour ago with some relief. Her vitals are stable at 98.1o F., Heart rate 89 bpm, 18 breaths/minute, 132/68 mmHg, O2 Saturation 98% on room air. She’s currently NPO until the need for dilation and curettage is ruled out. She has an IV in her left forearm, no fluids infusing at this time. She verbalized understanding of the findings and is visibly upset. She expresses concern about her family dealing with the loss and how she will tell them. She has been speaking with the staff about loss and is receptive to education regarding the next steps. Category Educational Needs Fall Risk Health change Pain level Physiological Needs Sensorium Needs Your response Explanation Increased acuity Jenny will need education regarding dealing with the loss both mentally and physically. Increased acuity She may be at increased fall risk related to bleeding, pain, and pain medication. Increased acuity She needs to be monitored for hemorrhage from the vaginal bleeding. Increased acuity The client rates their pain at 7/10. Increased acuity Client is grieving a loss and expresses concern about herself and others coping. Normal acuity No issues reported here. Physiological Your Description Response Explanation Acute Pain True Client rates pain 7/10 pain. Altered family processes True Roles have been changed due to the loss. Anxiety True Client is expressing anxiety over loss. Bleeding True Client is still having vaginal bleeding. Decreased cardiac output False Vitals are stable, no signs of cardiac compromise. Depression, risk for True Client has not relayed any feelings of depression. Grieving True Client is currently grieving a loss. Ineffective airway clearance False There are no reports of airway compromise. Ineffective coping False Client seems to be coping so far, expresses feelings and responding. Your Response Description Infection, risk for Nausea Suicidal ideations Safety Description Fall, risk Impaired communication Impaired mobility Knowledge deficit Use therapeutic 1 communication and express that you are here to listen if she wishes to talk. 2 2 3 3 True False False Your Response True False False True Explanation Client is at risk for infection is miscarriage is incomplete. Client no reports of nausea. Client has not expressed thoughts of suicide. Explanation Client may be a fall risk due to pain medication, pain, and bleeding. Client is able to express feelings at this time with staff. Client has no mobility issues have been identified. Expresses uncertainty about how to explain loss to others, resources should also be provided. Therapeutic communication should always be used. The nurse should offer to listen in case she does feel like talking. She might open up if given time. Statements could include “It sounds like you were looking forward to growing your family. I wish the ultrasound had shown better news.” Assess her overall condition and vital signs if available. Respect her wish to be alone at this time and ask if there is anyone to call/reassure you will return. Assess the condition of patient to ensure that she is stable to be left alone at this time. It is normal in the grieving process to not wish to speak to others for a time. She is stable and has not opened up so should be left alone. A call to a friend/family member may assist. 4 Ensure that call light in reach and leave the room. 5 Document the conversation. 4 5 1 1Assess vital signs. 2Assess amount of current vaginal bleeding. 2 3Administer pain medication as prescribed 3 4 4Educate about spontaneous miscarriage and about medication action and effects and evaluate understanding. 5Document event in the chart. 5 1 1Assess vital signs. 2 2Assess vaginal bleeding amount and odor. 3Estimate and compare Important to return to support the client. Always make sure the patient has access to call for help and is safe before leaving. Documentation should be completed for the physician and other staff to see and should be done last to include all the information needed. Assessing vital signs will ensure the patient is stable and that its ok to give pain meds. If vitals are abnormal it could indicate complications. ncreased pain could be caused by active miscarrying so bleeding should be assessed first. Immediate action will need to be taken if she is bleeding excessively. She has prn pain medication that she has been needing and using to relieve discomfort. Always educate patients about the medications they have received and what they can expect after taking them. It is important to document all that you’ve done for other providers to reference. An elevated temp, high heart rate, and/or low bp could be signs of complications and will need to be reported to provider. Increased bleeding could indicate an incomplete miscarriage. This needs to be addressed quickly. It is important to have some point of reference to determine how significant the 3 previous and current blood loss. 4Notify the healthcare 4 provider. 5 5Document findings and notification of healthcare provider. Explain to 1 Jenny about the plan of care. 2 2 changes are in bleeding amounts. The healthcare provider needs to be given a detailed description of the patient’s status so data should be gathered prior to calling. The nurse should anticipate the need to administer IV fluids and to check hemoglobin. Documentation should be done last to include all the information. The client needs to be educated on the plan of care. Ensure that the consent is obtained prior to the surgery. 3 Assess NPO status to ensure that she has been NPO for the proper period of time. 4 Administer pre-op medications as indicated. Give report to the operating room staff and ensure support is given to the client related to perinatal loss. 3 4 5 5 1 Assess Jenny’s current Vital signs should be checked quickly and regularly post-op to allow for baseline set for you and Obtaining the patient’s consent should always be done first. If they refuse the surgery or have questions for the provider then you would not proceed with other interventions. If the patient has not been NPO long enough, the surgery may be pushed back to allow sufficient time to pass. If it is determined that she needs to go regardless of NPO status, anesthesia will need to be made aware of her last food and drink. Pre-operative medications are generally given within 1 hour of surgery. OR staff receiving the patient needs to be given a full report prior to assuming her care including NPO status, the surgical consent, and pre-op medications. Support should be provided in a caring and sensitive manner due to perinatal loss. vital signs. to note any subtle changes that may indicate a problem. 2 Assess current bleeding. 2 3 Assess current urinary output. 4 Speak with Jenny and inform her that she is back in her room and that she is doing well. Assess her current pain level. Inform Jenny that her family is waiting and offer to bring them in to be with her. 3 4 5 5 Assess Jenny’s 1 current status/physical readiness for discharge. 2 2 3 3 Vital signs, bleeding, pain, and ability to void should be assessed for stability prior to discharge. Verify blood type. Education about follow-up with provider. 4 Educate about warning signs of complications. 5 Offer support for 4 Bleeding needs to be checked regularly as an increase can indicate a complication. Urine output would indicate hydration status and significance of estimated blood loss and cardiovascular stability. Client should void prior to discharge. Jenny should be updated about her status and be made comfortable. Pain is an important assessment but is normal after surgery so can be checked after the other things which could indicate issues. The client has the choice to see family members and who she wants to see. She may not have disclosed the pregnancy or may not want to see all family members. Family members may be updated as soon as possible but only after you have assessed the patient and determined that they are stable. If she is Rh- she would need Rh immune globulin prior to discharge. She should see her provider in 1-2 weeks to ensure safe physical recovery, and to discuss either birth control or planning next pregnancy if she expresses desire to try again. She should know when to call provider- for fever, increasing pain, or excessive bleeding, and be able to “teach back” explain warning signs in her own words. Let her know that grief after a pregnancy loss may take time, 5 pregnancy loss. that there may be some days she is especially sad, like her due date (when she expected to be having a baby), that she and her partner may not grieve the same way, to reach out for support from friends, or other sources as needed (counselor, support group, on line resources).