vSim ISBAR ACTIVITY

vSim ISBAR ACTIVITY INTRODUCTION Farangiza Lisa Djabbarova, RN on the maternity unit, KP5 at MSH Your name, positon (RN), unit you are working on SITUATION Patent’s name, age, specific reason for visit BACKGROUND Patent’s primary diagnosis, date of admission, current orders for patent ASSESSMENT Current pertnent assessment data using head to toe approach, pertnent diagnostcs, vital signs RECOMMENDATION Any orders or recommendatons you may have for this patent Olivia Jones, 23-year-old African American female G1P0 at 35 weeks’ gestation admitted for severe preeclampsia. Patient was admitted for continuous monitoring after finding proteinuria and development of mild preeclampsia, with increasing symptoms. Nausea, fatigue, epigastric pain, chest tightness, visual changes present. O.J. was diagnosed with severe preeclampsia, admitted on 1/24/21. Current orders for patient are NPO until serum lab results come back, bed rest w/ bathroom privileges. Take BP q1h x2 then q4h. Temperature, HR, RR all q1h. Breath sounds q4h, FHR/UC monitoring, DTR q1h, head to toe assessment q4h, continuous SpO2, IV care, ultrasound ordered, insert a foley catheter, place seizure pads, minimize all stimuli, NRB mask for SpO2 <92%. BP: 164/98 T: 99F RR: 22 HR: 110 SpO2: 92% Patient complains of visual changes (blurry vision with spots), headache, epigastric pain, nausea and wants to vomit. Crackles in lower lungs are present. Low platelets, RBCs, MCH, & MCHC. Elevated creatinine, BUN, & ALT/AST. Protein in the urine >455 mg over 24 hours. She has gained 3 pounds since prenatal visit 1 week ago. Protein dipstick is +4, negative ketones, negative glucose, +2 dependent edema, and facial puffiness. I believe the patient have seizure pads placed, with low environmental stimuli and limited visitors. O.J. should be continuously monitored for S/S of progressing preeclampsia to eclampsia. She should be a fall risk patient, as she should not be walking ad lib. Education should be provided for her condition and medications, and what lab results mean. Contraction frequency and duration should be monitored, with blood pressure a top priority every hour or so. PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: magnesium sulfate CLASSIFICATION: mineral/electrolyte replacement, IV antihypertensive PROTOTYPE: electrolytes/minerals SAFE DOSE OR DOSE RANGE, SAFE ROUTE IM/IV severe: 8-12 g/day in divided doses. Mild: 1 g q6h for 4 doses or 250 mg/kg over 4 hours. PURPOSE FOR TAKING THIS MEDICATION Treatment of hypomagnesemia and hypertension; prevention of seizures related to eclampsia and preeclampsia. PATIENT EDUCATION WHILE TAKING THIS MEDICATION Can cause drowsiness, decreased RR, cardiac dysrhythmias, hypotension, epigastric discomfort including N/V/D, muscle weakness, flushing, sweating, hypothermia Clinical Worksheet Date: Initials: OJ 2/24/21 Student Name: Diagnosis: severe preeclampsia Farangiza Lisa Djabbarova HCP: none Isolation: standard Assigned vSim: IV Type: peripheral antecubital forearm Age: 23 Fall Risk: N/A M/F: F Consults: none Length of Stay: 1 day Transfer: N/A Code Status: Full Allergies: NKA Fluid/Rate: Lactated Ringer’s 1000ml at 125 ml/hr Magnesium Sulfate 6g in 1000ml at 200ml/hr Olivia Jones Critical Labs: platelets: 98 RBC: 5 MCH: 28 MCHC: 12 Creatinine: 2.6 BUN: 32 ALT: 40 AST: 42 LDH: 220 Triglycerides: 180 Creatinine clearance: 154 Protein in urine: >455 mg/24h Other Services: none Consults Needed: none Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: OJ had a routine visit at 30 weeks’ gestation and we found that she has a BP of 146/92. Suspected premature rupture of membranes. She has gained 3 pounds since prenatal visit 1 week ago. Protein dipstick is +4, negative ketones, negative glucose, +2 dependent edema, and facial puffiness are all present and signs of preeclampsia. Patient was admitted for continuous monitoring after finding proteinuria and development of mild preeclampsia, with increasing symptoms. Nausea, fatigue, epigastric pain, chest tightness, visual changes present. Health History/Comorbities (that relate to this hospitalization): Mild preeclampsia, chronic HTN Shift Goals/ Patient Education Needs: 1. Education on preeclampsia and medications 2. Seizure precautions should be implemented 3. Maintain SpO2 >92% 4. Prevent falls Path to Discharge: Patient will understand her risk for seizures associated with condition of preeclampsia. Patient does not have any seizures or premature rupture of membranes. Fetal and maternal HR in normal ranges. Preeclampsia does not become eclampsia. BP does not get any higher and fetus is delivered thus Mother’s BP goes back down to normal ranges. Path to Death or Injury: Preeclampsia becomes eclampsia thus resulting in seizures. Placenta abruption calls for baby delivery preterm. Patient has irreversible organ damage. Alerts: What are you on alert for with this patent? (Signs & Symptoms) Management of Care: What needs to be done for this Patient Today? 1. Insert foley catheter 2. Assess IV site 3. Maintain bed rest 4. Bed is locked and lowest position What Assessments will focus on for this patent? (How will I identfy the above signs &Symptoms?) 5. Administer magnesium sulfate 1. BP increase 6. Check V/S frequently 2. Visual assessment for disturbances 3. Dip stick 1. seizures 2. visual changes 3. proteinuria Priorities for Managing the Patient’s Care Today 1. V/S List Complications may occur related to dx, procedure, comorbidites: 2. DTR 1. seizures 3. Liver function labs 2. organ damage 4. Seizure and fall precautions 3. preterm birth What nursing or medical interventions may prevent the above Alert or complicatons? 1. Padded bed rails 2. Assess BP every hour 3. Test urine for protein levels 4. Bed rest What aspects of the patient care can be Delegated and who can do it? PCA can check V/S frequently, provide comfort for bed rest, measure I&Os to an extent. Side rail padding and minimization of stimuli should be done by the nurse. Description/Pathophysiology Preeclampsia is characterized by high blood pressure after 20 weeks’ gestation. There is mild and severe which then becomes eclampsia. Mild preeclampsia is when the BP is >140/90 and severe is >160/110. The pathophysiology is mostly unknown, but we do know that vasospasms and hypoperfusion are involved. Eclampsia can cause pulmonary edema, oliguria, seizures, thrombocytopenia, and abnormal liver enzymes. Clinical manifestations/Nursing assessment Pitting edema, increased BP, >140/90, facial edema, weight gain, oliguria, headache, difficulty breathing, epigastric pain, visual changes, nausea, fatigue Diagnostic tests Ultrasound to monitor FHR Hepatic function panel to monitor for organ damage AST/ALT to monitor for organ damage CBC to monitor for platelets, RBCs, MCH, MCHC Urine dip stick to monitor for proteinuria, a warning sign Treatment/Procedures Lactated Ringer’s 1000ml at 125 ml/hr Magnesium Sulfate 6g in 1000ml at 200ml/hr Insert foley catheter HEALTH PROBLEM: Severe preeclampsia Etiology/causes/risk factors Although triggering factors are unknown, risk factors include familial history, periodontal disease, African American descent, and preexisting conditions such as renal disease, collagen disorders, chronic hypertension, and diabetes. Nursing interventions/considerations Monitor labs CBC, dip stick, liver function tests Auscultate lung sounds Nursing Diagnoses Attach electronic FHR monitor Deficient fluid volume r/t osmotic pressure AEB weight gain, nausea, epigastric pain, headache, visual changes. Obtain ultrasound Assess for dependent edema Monitor SpO2 Limit stimuli (light, sound, visitors) Assess for visual changes Provide emotional support Risk for maternal injury r/t seizures associated with eclampsia. Decreased cardiac output r/t hypovolemia AEB facial puffiness, edema, high BP, chest tightness (SOB). Provide patient education Maintain bed locked and in lowest position Assess deep tendon reflexes Priority diagnosis/interventions Monitor BP and HR frequently Remediation/Other Patient Teaching Reduced activity, strict bed rest, IV antihypertensives, such as magnesium sulfate, and preparation for delivery if progression occurs. Educate on condition, and meds, methods and means to manage condition. Administer meds as ordered Monitor for progression of preeclampsia Pad railings and implement seizure precautions