Maternal Newborn Part 1

Jennifer Humes Room 301 Jennifer Humes, 30-year-old Caucasian female, G4 T2 P0 A1 L2, 33 5/7 weeks gestation. History of chronic hypertension and gestational hypertension with this pregnancy. Nifedipine XL 30 mg daily. NKDA. Previous pregnancies uncomplicated with NSVDs. One spontaneous abortion at 10 weeks gestation. Woke up early morning feeling wet; wasn’t sure if leaking urine or membranes ruptured. Turned on light and it was blood. Asked a neighbor to come over to watch other children and husband brought her to hospital. They are making phone calls to get family member to come and take care of 5 and 2-year old children. Anxious about this pregnancy and bleeding too. Has mild abdominal pain and contractions. You responded correctly to 5 out of 6 evaluations: Category Educational Needs Fall Risk Health change Pain level Physiological Needs Sensorium Needs Your response Explanation Increased acuity Status assessment reports r/t change in condition. Increased acuity Status assessment reports r/t 34 weeks gestation and pain, change in center of gravity. Increased acuity Status assessment reports r/t complication of pregnancy and bleeding. Increased acuity Status assessment reports r/t abdominal pain and mild contractions. Increased acuity Status assessment reports r/t concern about condition and care of other children. Normal acuity Status assessment reports no problems related to sensorium indicated in the report. Jenny Theriot Room 302 Jenny Theriot, 30 y/o G1P0 at 31 weeks’ gestation. She has had an uncomplicated pregnancy until this morning when she woke up with clear fluid leaking from her vagina. She denies having contractions but says she isn’t really sure what she is feeling. She presents to the Obstetrics Triage Unit, looking distraught and crying, and says she doesn’t understand what is going on. Category Educational Needs Fall Risk Health change Pain level Physiological Needs Sensorium Needs Your response Increased acuity Increased acuity Increased acuity Decrease acuity Increased acuity Normal acuity Explanation Status assessment reports leaking of fluid from vagina, possible contractions and preterm delivery. These should be the subject of teaching and support for the client. Status assessment reports the client is pregnant; this changed her center of gravity and balance. Status assessment reports leaking of fluid from vagina and possible contractions. Status assessment does not indicate report of pain. Status assessment reports leaking of fluid from vagina, possible contractions. Status assessment Kesha Jackson Room 303 Kesha Jackson, Kesha Jackson is a G1P0, gestational age of 33.1. She came in complaining of contractions for 2 hours that are now every 5 mins. She is unsure about rupture of membranes, denying vaginal bleeding and recent intercourse. She states the baby is active. She rates her pain an 8/10. Her current vital signs are 98.1o F., 92 BPM, 16 breaths/min, 122/64 mmHg, 99% on room air. The fetal heart rate is 135 baseline but is not yet reactive. Cervical exam reveals that she is not dilated or effaced, and the baby’s head is not engaged in the pelvis. She has no medical history and NKA. In obtaining her history, it was learned that she is 15 years old, currently homeless, and has been staying with various friends. She does have some supplies including diapers, wipes, and some clothing that she received from a friend. She expresses the desire to take her baby home with her. She is receptive to teaching and assistance she just has been unsure of how to obtain it. She came to the OB triage via a bus. Category Educational Needs Fall Risk Health Change Pain Level Psychological Needs Sensorium Your response Explanation Increased Status Assessment reports Kesha will need a lot of education regarding preterm labor precautions, resources for acuity assistance, and caring for her baby once it arrives Increased Status Assessment reports Client is at increased of fall due to changing center of gravity and balance. acuity Increased Status Assessment reports in addition to the pregnancy, there are now additional health issues due to the preterm acuity labor. Increased Status Assessment reports she rates her pain an 8/10 acuity Increased Status Assessment reports Kesha is homeless, is pregnant, is a teen with developing coping mechanisms, and has acuity a lack of a consistent support system. Normal Status Assessment reports no issues reported here. Category Your response acuity Explanation Stephanie Gold Room 304 Stephanie Gold, 19-year-old Caucasian female, G1 T0 P0 A0 L0, 32 weeks gestation. Uncomplicated pregnancy except for anemia treated with PO iron. States 3 times in last week has called on-call obstetrician about fatigue, body aches, mild nausea during the evening. The client reports, “I don’t feel well, I haven’t vomited, but nausea makes me not want to eat too much. I am drinking ok, just want to eat bland foods.” Rest and acetaminophen were recommended. Client is first-year nursing student and states several students have had a “GI bug”. States during day felt better and went to school all but one day. No fever. She stated: “Can’t be absent from nursing school!” No contractions, leaking of fluid or vaginal bleeding. Came in this morning (Saturday) due to pain by right rib cage. States this is new today. Boyfriend accompanies client. You responded correctly to 6 out of 6 evaluations: Category Educational Needs Your response Increased acuity Explanation Status Assessment reports r/t change in condition Category Fall Risk Your response Increased acuity Health Change Increased acuity Pain Level Increased acuity Psychological Needs Increased acuity Sensorium Normal acuity Explanation Status Assessment reports r/t physiological shifts of pregnancy/center of gravity Status Assessment reports r/t malaise/nausea/pain during pregnancy Status Assessment reports r/t right upper quadrant pain Status Assessment reports r/t concern about her baby’s health/her health and absence from nursing school Status Assessment reports no indication in report that there is a change in sensorium Physiological Your Response False Description Deficient Fluid Volume Imbalanced Nutrition Injury, risk for fetal Injury, risk for maternal Nausea Safety False True True True Description Fall Risk Injury, risk for maternal Love and Belonging Explanation Status assessment reports no generalized edema from fluid shift from intravascular to extravascular at this assessment/nausea not significant enough to cause deficit. Status assessment reports assessments do not show nutrition has been substantially impacted by slight nausea. Status assessment reports r/t risk for uteroplacental insufficiency secondary to vasospasm if abdominal pain and malaise/elevated BP indicate preeclampsia/HELLP syndrome. Status assessment reports r/t hypertension and vasospasm and potential decreased renal perfusion. Status assessment reports experiencing slight nausea off and on this week. Your Response True True Explanation Status assessment reports r/t shifting center of gravity at 32 weeks gestation and in the third trimester. Status assessment reports r/t risk for worsening preeclampsia to eclampsia and seizures. Description Anxiety Disabled Family Coping Health Maintenance; Ineffective 1 Explain all plan of care to client and significant other. 2 3 4 5 Your Response Explanation True Status assessment reports r/t unknown impact of current complication on mother and fetus. False Status assessment reports no evidence of inappropriate family coping. Boyfriend accompanies. Risk for r/t High Risk Pregnancy and Financial Concerns. True Status assessment reports r/t deficient knowledge about high risk pregnancy. Explanation of plan of care helps put client and significant other at ease, decrease anxiety. The must be done first. Bedrest/side-lying position. Left lateral recumbent position decreases pressure on vena cava, therefore increasing venous return and placental and renal perfusion. This ensures that the fetus is also well perfused and is a priority. CBC, Chemistry Panel, LFT, Contact the lab to come and draw these labs. The results of the 24-hour urine for protein lab will take several minutes and will drive the plan of care for and creatinine. the client. Continuous EFM. Client and healthcare team are concerned about fetus. Hearing fetal heart will decrease client’s anxiety prior to taking her VS. Verifies fetal wellbeing. EFM has been in place but ultrasound and tocotransducer may need to be adjusted after turning client onto her left side. Hourly VS and DTR. Client’s BP was elevated and DTR were brisker than average. By the time other actions have been taken, it will be close to time for the hourly assessments. Elevate 1 and pad side rails. 2 Her DTRs are +3 so she is slightly hyper-reflexic and at risk for seizures. Padding side rails protects her from injury if she has a seizure. Safety first! Ensure oxygen and suction are working properly. 3 Emergency medications brought to the client’s room or verified as accessible. 4 Bring extra pillows to enhance comfort in side-lying position and place between knees, behind back, and under abdomen. Bring bedpan, graduated cylinder, 24-hour urine container, ice into the room. 5 6 Educate client and significant others about 24-hour urine collection, I&O Airway and breathing precautions next. If client has a seizure, suction may be needed to clear airway. (She is already positioned on her side) During a seizure, client would have a period of apnea which would cause fetal hypoxemia. Applying oxygen to mother would increase oxygen available to fetus. Ensure both are working before needed in an emergency situation. Magnesium sulfate, calcium gluconate, hydralazine, nifedipine are often in an emergency “toolbox” and brought to client’s room for immediate access if needed; anticipating one or more of these meds will be ordered if complications such as preeclampsia, eclampsia, or HELLP syndrome occur. This is done as per agency policy. Enhancing comfort in the side-lying position will enable the client to maintain this position. Side-lying decreases pressure on the vena cava, increases venous return, placental and renal perfusion. Comfort measures are completed after emergency interventions. Healthcare provider ordered 24-hour urine so bringing supplies for this collection would be necessary. The nurse may include intake and output in the care plan independently. At least 30 mL of hourly urine output demonstrates minimal kidney function. Left lateral position enhances renal perfusion, thereby decreasing angiotensin levels, and promotes diuresis. 24 hour I&O documents positive or negative fluid balance. Educating and involving the client and significant others in the plan of care helps to decrease anxiety and empower them as and documenting oral intake. 1 Educate the client and her significant other about the medication. 2 3 important members of Actively involving client in their own care is a safety strategy, decreases anxiety, and gives the opportunity for verbal consent of the treatment. Initiate peripheral IV with Lactated ringer’s infusing at 50 mL/hour. Piggyback magnesium sulfate solution into primary IV, set infusion at 400 mL/hour for 15 minutes; volume to be infused 100 mL. IM betamethasone 12 mg. 4 5 Change infusion rate to 50 mL/hour Magnesium sulfate 20 grams/500 mL for the remainder of 400 mL. Magnesium sulfate is a high alert medication and should be administered as a secondary medication. A primary line is started with an isotonic solution, like Lactated Ringer’s. To reduce the risk of pulmonary edema, total intake should be less than 125 mL/hour. An initial loading dose of 4 to 6 grams over 15-30 minutes helps raise magnesium blood levels to a therapeutic level of 4-7 mEq/L and prevent eclamptic seizures. While the loading dose of magnesium sulfate is infusing, administer the IM steroid injection to enhance fetal lung maturity for gestations less than 34 weeks. Neonatal benefit is maximized when the interval between the first injection and birth is longer than 48 hours, but benefits begin within 4 hours of administration. The benefit of one injection is unclear but is often given without harm. Turn head to one 1 side and ensure pillow under back and shoulder is snug. 2 3 4 5 6 1 Assess vital signs and FHR pattern post seizure. Keep airway patent and provide for safety from head injury. Side rails are up and padded. Call for assistance but do not leave client. Keep family informed of situation. Administer oxygen via non-rebreather mask at 10 L/min. Administer ordered 4 grams loading dose of magnesium sulfate IV in 15 minutes. Observe and document convulsion activity. Administer IV lorazepam 2 mg over 3-5 minutes. Assess post-seizure status of both client and fetus. Fetal distress may occur from hypoxemia during the seizure. Monitor VS frequently until The nurse should call for help but do not leave the bedside. Informing the family helps lower anxiety. Eclamptic seizures are frightening to watch. During the clonic phase of the seizure, the client will become apneic and may result in hypoxemia to the fetus. Respirations begin with long, deep inhalation. Having the 100% O2 in place will provide for additional oxygen to both mother and fetus. Since eclampsia occurred after initiating magnesium sulfate, additional magnesium sulfate should be given. It is the drug of choice for treating eclamptic seizures and preventing repeated seizures. Each stage of the convulsion should be timed and documented descriptively. Magnesium sulfate is the drug of choice over other antiseizure medications because it does not depress the gag reflex. Lorazepam or diazepam are only given if the client is receiving therapeutic levels of magnesium and experiences repeated eclamptic seizures. THIS OPTION IS NOT USED AS THE CLIENT IS HAVING HER FIRST SEIZURE. 2 2 3 3 4 Assess for incontinence, provide hygiene, insert indwelling urinary catheter. 5 Prepare to assist with the birth process/instruct client and significant other. 4 5 stable. Continue oxygen at 10 L/min per mask. Assess uterine activity and abdominal focused assessment. Next, administer oxygen to support oxygenation of the client and her fetus and resolve hypoxia. During the seizure the uterus may become hypercontractile and hypertonic. Membranes may rupture, cervix may dilate rapidly. The placenta may separate resulting in abruptio placenta. A rigid broad-like abdomen, pain, and tenderness could be signs of this condition. The client may be incontinent during the convulsion. Provide peri-care and insert and indwelling catheter with urinometer, for hourly output. Urinary output decreases when there is a reduction of glomerular filtration rate. Report output of < 30 mL/hour. The cervix may dilate rapidly during a convulsion as the uterus is hypercontractile and hypertonic. Eclampsia alone is not an indication for an immediate cesarean delivery- Route of birth is determined by labor progression, maternal and fetal condition, and gestational age. If abruptio placenta is confirmed with ultrasound and cervix is not dilated, cesarean birth would occur.