covid 19 V Delivery

covid 19 V Delivery

 

Please complete a Problem Based Care Plan and Concept Map for COVID 19 Vaginal Delivery with a Non-vigorous Newborn.

 

Objectives:

Cognitive:

  1. List appropriate Personal Protective Equipment (PPE) use for all individuals who enter the room.
  2. Discuss how COVID-19 is transmitted.
  3. Describe management of a patient during labor and delivery with COVID-19.
  4. Describe management of immediate postpartum care for a patient with COVID-19 infection.

Technical:

  1. Perform appropriate PPE donning and doffing.
  2. Apply appropriate infection prevention and control (IPC) precautions
  3. Perform correct and timely maternal assessment for both COVID-19 (vital signs, oxygenation status, etc.) and for labor (abdominal and cervical exams, fetal heart rate, etc.).
  4. Call for help from team early enough to prepare for COVID-19 exposed baby.
  5. Perform neonatal resuscitation with effective positive pressure ventilation.
  6. Complete the steps of Active Management of the Third Stage of Labor (AMTSL).
  7. Perform inspection of the placenta.
  8. Conduct post-resuscitation and routine care of the baby, per COVID-19 guidelines.
  9. Identify safe and warm place for baby after successful resuscitation.

Behavioral:

  1. Kind and respectful communication with the mother and any labor companions
  2. Kind and respectful care of the mother and baby.
  3. Communication with the team, as relevant:
    1. SBAR
    2. Check-Back
    3. Call-Out
    4. Thinking-Out-Loud
    5. Two-Challenge Rule
    6. Complete and appropriate communication

 

 

 

 

 

Case: Annette is a 28-year-old, Gravida 4, Para 3, gestational age: 38 weeks. She arrived at the facility one day ago, with complaints of a fever, cough, and shortness of breath for the previous two days. She was admitted into an isolation area in the facility for monitoring and was given oxygen due to her shortness of breath. Upon admission, she was not in labor, and her cervix was 3/50/-1. She was tested for COVID-19 upon admission and was positive. She has been stable for the last 24 hours, is no longer on oxygen, and is wearing a mask.

Annette has been complaining of pain and having contractions for the last 2 hours. 15 minutes ago, her membranes spontaneously ruptured. SVE at the time revealed she is 8/75/0. Meconium stained fluid noted upon rupture of membranes.

 

Brief Medical History:

  • 6 prenatal care visits
  • 3 vaginal births (has a 6-year-old, 4-year-old, and a 2-year-old)
  • Current meds:
    • PNV daily
    • Folic acid daily
    • Iron supplementation daily
    • Acetaminophen 1000mg PO PRN q 6 hours for fever over 100.4
  • Positive for COVID-19 (diagnosed yesterday)

 

Please answer the following questions:

  1. What is the COVID-19 virus?
  2. What are the signs and symptoms of COVID-19?
  3. When should you call for assistance during the delivery of a COVID-19 positive patient, and who should be present?
  4. What Personal Protective Equipment, commonly called PPE, should providers and nurses wear when caring for a suspected or confirmed case of COVID-19?
  5. What are the steps to donning and doffing PPE after caring for a patient with confirmed or suspected COVID-1
  6. How does a COVID-19 infection change the management of the mother during delivery?
  7. Is COVID-19 an indication for a cesarean?
  8. What vital signs should be routinely taken during labor? Are there any additions for COVID-19?
  9. What are the steps for the active management of the third stage of labor?
  10. How does neonatal resuscitation change for the baby of a COVID-19 positive mother?
  11. What are the steps to the immediate assessment and initial interventions for a neonate that is non-vigorous (compromised) at birth?
  12. What is APGAR scoring? How is it done?
  13. What is the correct procedure and tempo for bag and mask ventilation of a neonate?
  14. Does a COVID-19 positive mother need to be separated from her baby, if her baby is healthy?

 

PROBLEM‐BASED CARE PLAN EXAMPLES

The following are examples of how a student may complete a Problem‐Based Care Plan using Lippincott Advisor. These examples can be used when creating a care plan for a patient in the clinical setting, while working through a vSim, and incorporating case‐based learning such as an Interactive Case Study.

In this example, the student is working through a case study provided by the instructor. The patient is a 78‐year‐old male admitted for shortness of breath due to a medical diagnosis of heart failure. The student receives the patient’s history and assessment findings to include activity intolerance, but with clear lung sounds and edema to lower extremities. The student is required to create a care plan for this patient. One example uses a traditional care plan with a linear approach and the second example uses a concept map.

Please note these examples are for demonstration purposes. They provide potential responses.

 

TRADITIONAL CARE PLAN EXAMPLE

  • Example of a traditional worksheet when creating a Problem‐Based Care

 

Problem-Based Care Plan Worksheet
WHAT ASSESSMENT DATA DOES THE NURSE FIND AS PERTINENT (RECOGNIZE CUES)?
Increase in RR and work of breathing while ambulating to the bathroom

Drop in O2 sats from 95% to 89% on RA while ambulating

WHAT IS THE DISEASE PROCESS CAUSING THESE ASSESSMENT FINDINGS (ANALYZE CUES)?
The patient has an enlarged heart so it cannot pump oxygen to the body on exertion.

There is an imbalance between supply and demand. Lippincott Advisor Diseases and Conditions

WHAT IS THE MAIN PROBLEM WITH THE PATIENT THE NURSE CAN TREAT (PRIORITIZE HYPOTHESES)?
Activity Intolerance

Lippincott Advisor Problem‐Based Care Plans 

WHAT IS THE GOAL FOR THE PATIENT (GENERATE SOLUTIONS & TAKE ACTION)? CREATE SPECIFIC, MEASURABLE, ACHIEVABLE, REALISTIC, AND TIMEABLE (SMART) OUTCOMES.
The patient will exhibit tolerance for increased physical activity by the end of the shift.

Lippincott Advisor Problem‐Based Care Plans 

WHAT INTERVENTIONS WILL THE NURSE IMPLEMENT WHEN CARING FOR THIS PATIENT (GENERATE SOLUTIONS & TAKE ACTION)? INCLUDE THE EVIDENCE. LIST INTERVENTIONS IN ORDER OF PRIORITY. INCLUDE COLLABORATIVE AND NURSE‐INITIATED INTERVENTIONS.
·         Provide supplemental oxygen as ordered and monitor the patient’s response. Lippincott Advisor Problem‐Based Care Plans Rationale: Oxygen therapy helps meet the increased myocardial workload as the heart tries to compensate. Administering oxygen helps to meet cellular needs. Lippincott Advisor Diseases and Conditions > Procedures

·         Assess patient’s cardiopulmonary response to activity Lippincott Advisor Problem‐Based Care Plans

·         Instruct the patient on exercises to increase strength and endurance. Advance activity, as tolerated. Lippincott Advisor

Problem‐Based Care Plans

Collaborate with Physical Therapy Lippincott Advisor Problem‐Based Care Plans

HOW WILL THE NURSE EVALUATE THE PATIENT’S RESPONSE (EVALUATE OUTCOMES)? AND WHAT WAS THE PATIENT’S RESPONSE TO THE INTERVENTIONS?
Monitoring the patient’s oxygen saturation when ambulating. Observe for signs and symptoms of distress while ambulating. Assess the need for oxygen.

Communicate with physical therapy about recommendations and their assessment findings

WHAT OTHER PROBLEMS COULD THE NURSE LINK TO THIS PATIENT PROBLEM?
Fluid overload Lippincott Advisor Diseases and Conditions

 

 

CONCEPT MAP

  • Example of a Concept Map when creating a Problem‐Based Care

 

CONCEPT MAP WORKSHEET
  DESCRIBE DISEASE PROCESS AFFECTING PATIENT

(Include Pathophysiology of Disease Process) 

 
  The patient has an enlarged heart so it cannot pump oxygen to the body on exertion. There is an imbalance between supply and demand.

Lippincott Advisor Diseases and Conditions

 
 
  DIAGNOSTIC TESTS

(Reason for Test and Results) 

    PATIENT INFORMATION INCLUDING

PRIORITY PATIENT PROBLEM(S)

    ASSESSMENT FINDINGS  
  BNP‐ 350 pg/mL (BNP is released by the heart in response to volume overload. To assess severity of heart failure) Lippincott Advisor Diagnostic Tests 78 year old patient with Heart Failure

Admitted for “shortness of breath”

#1 Activity Intolerance

Lippincott Advisor Problem‐Based Care Plans

Fluid Overload

Lippincott Advisor Problem‐Based Care Plans

Increase in RR and work of breathing while ambulating to the bathroom

Drop in O2 sats from 95% to 89% on RA while ambulating

Clear lung sounds

Edema to lower extremities

 
  PLAN OF CARE/ INTERVENTIONS  
  ·         Provide supplemental oxygen as ordered and monitor the patient’s response. Lippincott Advisor Problem‐ Based Care Plans Rationale: Oxygen therapy helps meet the increased myocardial workload as the heart tries to compensate. Administering oxygen helps to meet cellular needs. Lippincott Advisor Diseases and Conditions > Procedures

·         Assess patient’s cardiopulmonary response to activity Lippincott Advisor Problem‐Based Care Plans

·         Instruct the patient on exercises to increase strength and endurance. Advance activity, as tolerated.

Lippincott Advisor Problem‐Based Care Plans

·         Collaborate with Physical Therapy Lippincott Advisor Problem‐Based Care Plans

·         Administer ordered medication (furosemide) for fluid volume overload Lippincott Advisor Problem‐Based Care Plan

 

 

 

Problem-Based Care Plan Worksheet
WHAT ASSESSMENT DATA DOES THE NURSE FIND AS PERTINENT (RECOGNIZE CUES)?
 
WHAT IS THE DISEASE PROCESS CAUSING THESE ASSESSMENT FINDINGS (ANALYZE CUES)?
 
WHAT IS THE MAIN PROBLEM WITH THE PATIENT THE NURSE CAN TREAT (PRIORITIZE HYPOTHESES)?
 
WHAT IS THE GOAL FOR THE PATIENT (GENERATE SOLUTIONS & TAKE ACTION)? CREATE SPECIFIC, MEASURABLE, ACHIEVABLE, REALISTIC, AND TIMETABLE (SMART) OUTCOMES.
 
WHAT INTERVENTIONS WILL THE NURSE IMPLEMENT WHEN CARING FOR THIS PATIENT (GENERATE SOLUTIONS & TAKE ACTION)? INCLUDE THE EVIDENCE.

LIST INTERVENTIONS IN ORDER OF PRIORITY. INCLUDE COLLABORATIVE AND NURSE‐INITIATED INTERVENTIONS.

 
HOW WILL THE NURSE EVALUATE THE PATIENT’S RESPONSE (EVALUATE OUTCOMES)? AND WHAT WAS THE PATIENT’S RESPONSE TO THE INTERVENTIONS?
 
WHAT OTHER PROBLEMS COULD THE NURSE LINK TO THIS PATIENT PROBLEM?
 

 

 

CONCEPT MAP WORKSHEET
  DESCRIBE DISEASE PROCESS AFFECTING PATIENT

(Include Pathophysiology of Disease Process) 

 
     
 
  DIAGNOSTIC TESTS

(Reason for Test and Results) 

    PATIENT INFORMATION INCLUDING

PRIORITY PATIENT PROBLEM(S)

    ASSESSMENT FINDINGS  
         
  PLAN OF CARE/INTERVENTIONS  
     

 

GRADING RUBRIC

USING THE RUBRIC

  • Students: Prior to the assignment, students can use the rubric to prepare for the requirements associated with the creation of a patient care plan. The student can utilize this rubric to perform a self‐assessment of their patient care plan prior to submitting their assignment. The rubric provides transparency related to the expectations for grading of the student’s submitted

 

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Solution

Problem-Based Care Plan Worksheet
WHAT ASSESSMENT DATA DOES THE NURSE FIND AS PERTINENT (RECOGNIZE CUES)?
Ø  Elevated pulse rate (beyond 100)

Ø  Fever beyond >100.4°F

Ø  Elevated respiratory rate > 30 breaths/min

Ø  Low oxygen saturation ((< 93%)

Ø  SVE 8/75/0

WHAT IS THE DISEASE PROCESS CAUSING THESE ASSESSMENT FINDINGS (ANALYZE CUES)?
The patient has a corona virus infection along the respiratory tract and the lungs. The infection is causing an inflammatory response in the endothelial cells and lung tissues, resulting in fever and impaired air passage thus inadequate air supply to the lungs. lung inflammation causes elevated respiratory rate and the low oxygen saturation. The patient is 38 weeks pregnant, and already experiencing cervical contractions, thus the SVE is 8/75/0.
WHAT IS THE MAIN PROBLEM WITH THE PATIENT THE NURSE CAN TREAT (PRIORITIZE HYPOTHESES)?
Cervical contractions
WHAT IS THE GOAL FOR THE PATIENT (GENERATE SOLUTIONS & TAKE ACTION)? CREATE SPECIFIC, MEASURABLE, ACHIEVABLE, REALISTIC, AND TIMETABLE (SMART) OUTCOMES.
·         The patient will be able to breath with ease by the end of the day

·         The oxygen saturation levels will improve by the end of the day

·         The patient will have uneventful vaginal delivery

·         The risk of transmitting corona virus will be successfully controlled by the end of delivery.

WHAT INTERVENTIONS WILL THE NURSE IMPLEMENT WHEN CARING FOR THIS PATIENT (GENERATE SOLUTIONS & TAKE ACTION)? INCLUDE THE EVIDENCE.

LIST INTERVENTIONS IN ORDER OF PRIORITY. INCLUDE COLLABORATIVE AND NURSE‐INITIATED INTERVENTIONS.

Ø  Administer  oxygen therapy.

Rationale: Oxygen therapy increases oxygen saturation and helps to meet cellular needs

Ø  Monitor the patient vitals regularly

Rationale: to assess for deterioration.

Ø  Put the patient in isolation in a highly ventilated room and provide a mask to wear during the delivery process

Rationale: to reduce the risk of transmitting corona virus to the care providers and the baby (Nolan et al., 2020).

 

 

 

 

HOW WILL THE NURSE EVALUATE THE PATIENT’S RESPONSE (EVALUATE OUTCOMES)? AND WHAT WAS THE PATIENT’S RESPONSE TO THE INTERVENTIONS?
Ø  Monitor the patient’s vitals (oxygen saturation, heart rate, respiration rate, blood pressure and temperature)

Ø  Observe for signs and symptoms of distress (Trevisanuto et al.,2020).

WHAT OTHER PROBLEMS COULD THE NURSE LINK TO THIS PATIENT PROBLEM?
Pneumonia

Rationale: it’s a covid 19 complication

 

CONCEPT MAP WORKSHEET
  DESCRIBE DISEASE PROCESS AFFECTING PATIENT

(Include Pathophysiology of Disease Process) 

 
  The patient has a corona virus infection in the lungs and the respiratory tract, causing inflammatory response, that is impairing entry of oxygen in the lungs. There is limited supply of oxygen compared to the demand. The patient is 38 weeks pregnant and is experiencing cervical dilation in preparation for vaginal delivery  
 
  DIAGNOSTIC TESTS

(Reason for Test and Results) 

    PATIENT INFORMATION INCLUDING

PRIORITY PATIENT PROBLEM(S)

    ASSESSMENT FINDINGS  
  v  Covid 19 test (throat swab)

 

Rationale: To assess for presence of corona virus.

v  Serial cervical examinations

Rationale: To assess for cervix dilation and labor onset

·         28-year-old 38 weeks pregnant

·         Admitted 24 hours ago with a 2-day history of fever, cough, and shortness of breath.

·         Complaining of pain and having contractions for the last 2 hours.

·         Raptured membranes 15 minutes ago.

·         Meconium-stained fluid noted upon rupture of membranes.

Ø  Elevated pulse rate (beyond 100)

Ø  Fever beyond >100.4°F

Ø  Elevated respiratory rate > 30 breaths/min

Ø  Low oxygen saturation ((< 93%)

Ø  Positive for COVID-19

Ø  SVE 8/75/0

 
  PLAN OF CARE/INTERVENTIONS  
  ·         Administer supplemental oxygen.

Rationale: Oxygen therapy increases oxygen saturation and helps to meet cellular needs.

·         Monitor the patient vitals regularly during labor

Rationale: to assess for deterioration in patients’ status (Nolan et al., 2020).

·         Put the patient in isolation in a highly ventilated room and provide a mask to wear during the delivery process.

·         Rationale: to reduce the risk of transmitting corona virus to the care providers and the baby.

·         Assist the patient in vaginal delivery while wearing PPE and in a highly ventilated room

·         Rationale: to reduce the risk of infection

·         Administer the steps for the active management of the third stage of labor: treat prophylactic uterotonic, clamp the cord early and controlled cord traction.

·         rationale: to reduce the risk of birth complications (Trevisanuto et al.,2020).

·         Separate the baby and the mother after delivery, and have the mother wear a mask and practice good hand hygiene during breastfeeding.

·         Rationale: To reduce the risk of transmitting the corona virus to the baby (Nolan et al., 2020).

 

 

References

Nolan, J. P., Monsieurs, K. G., Bossaert, L., Böttiger, B. W., Greif, R., Lott, C., … & Wyllie, J. (2020). European Resuscitation Council COVID-19 guidelines executive summary. Resuscitation153, 45-55. https://doi.org/10.1016/j.resuscitation.2020.06.001

Trevisanuto, D., Weiner, G., Lakshminrusimha, S., Azzimonti, G., Nsubuga, J. B., Velaphi, S., … & Putoto, G. (2020). Management of mothers and neonates in low resources setting during covid-19 pandemia. The Journal of Maternal-Fetal & Neonatal Medicine, 1-12. https://doi.org/10.1080/14767058.2020.1784873

 

 

 

 

 

 

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