Please complete a Problem Based Care Plan and Concept Map for Vaginal Delivery
I uploaded the example so follow that, please
|A. SCENARIO LEARNING OBJECTIVES
|1. Utilize principles and care practices related to normal labor and delivery.
|2. Implement critical thinking and clinical decision-making skills necessary to interpret data.
|3. Integrate understanding of multiple dimensions of patient-family centered care.
|4. Provide safe care to laboring patients, prioritizing and implementing interventions for mother and fetus.
|Specific Learning Objectives
|1. Accurately assess the laboring mother and estimate labor progress based on client responses.
|2. Recognize normal fetal heart rate pattern.
|3. Implement appropriate nursing interventions at this point in the labor process.
|4. Communicate relevant patient information to team using SBAR tool.
|5. Effectively communicate with client throughout simulation to keep informed and relieve anxiety.
|6. Perform pain assessment and reassure patient realistically.
|7. Engage family members to support patient in laboring process.
|Critical Learner Actions
|1. Identifies self and role to patient and family members.
|2. Performs hand hygiene.
|3. Identifies patient using 2 identifiers.
|4. Prioritizes assessment for both mother and fetus.
|5. Attaches fetal monitor.
|6. Communicates calmly with patient and family members while implementing interventions.
|7. Supports patient while primary nurse performs vaginal check to assess labor progress.
|8. Recognizes signs of imminent delivery.
|9. Reassesses mother and fetal heart tracing throughout.
|10. Considers patient need for privacy and need for family support when making decisions about care.
|B. PRE-SCENARIO LEARNER ACTIVITIES
|q Normal Labor and Delivery
|q General survey and focused assessment of newly
admitted patient in active labor
|q Pain theory related to child birth
|q Recognition of and interventions for normal fetal
|q Pharmacology of medications administered
during intra-partum period.
|q Comfort measures for laboring patient including
|q Therapeutic communication with patient and
|q Dimensions of patient-family centered care in
dealing with distressing situations
|q SBAR communication with interprofessional
|q Non-medicinal measures to support patient in active
|Code Status: Full
|Spiritual Practice: Catholic
|Ethnicity: Puerto Rican
|Primary Language spoken:
|1. History of present illness
|Chief Complaint: Excruciating abdominal pain.
Visiting from Florida visiting sister and in complete denial of pregnancy. Her parents are first generation Puerto Rican immigrants. Parents and sister are totally unaware she is pregnant. Because of her denial she has had no prenatal care. At her sister’s home at 0100 she begins to experience strong abdominal cramps. She does not tell her sister until 0700 and states she has a bad stomach ache. Her sister sees she is in a lot of pain and
immediately takes her to the nearest hospital.
|Primary Medical Diagnosis
|Full term pregnancy
|2. Review of Systems
|Alert, oriented, cooperative, fearful
|Regular sinus rhythm, no gallops, rubs or murmurs, apical clear, pulses +4 radial and
|Clear to A&P
|Voiding clear urine, no hepatomegaly felt
|Distended, full term pregnancy
|Full term pregnancy
|No bruising or bleeding noted
|Moves all extremities well. Spine within normal limits
|Clear without abrasions
|Normal Hispanic teenager
|Sexually active, no reported drug, smoking or alcohol history
|Alternative/ Complementary Medicine Hx
|3. Current medications
|4. Laboratory, Diagnostic Study Results
|ABO Blood Type:
Due to the running out of space problem on the actual worksheet I have copied the statements here:
WHAT ASSESSMENT DATA DOES THE NURSE FIND AS PERTINENT (important) (RECOGNIZE CUES)?
Risk factors: Young age of 16, nulliparity, late prenatal care, lack of support system, underweight for current gestation.
Current problem: Hypertensive with BP 150/80 mm Hg, pedal edema. Labs: urine protein 400mg, Why is this significant? What does it tell you? Platelet 80,000, ALT 70 U/L, AST 90 U/L, Cr 12 mg/dL Again, what do these lab values tell you? Are they normal? (You have to know what the normal ranges are!)
What we would hope for in any care plan is Lab value x is normal, or abnormal. Thinking about a normal labor patient, we do a CBC on admission to the hospital for labor. Why? 1. Anemia is common in pregnancy 2. To know BASELINE values so we can see if there are major or concerning changes if there is a bleeding event (All women will lose at least a little blood with birth, as low as 100ml and as high as multiple liters in the case of hemorrhage-how did the blood loss affect them?) If Susie Lou has an admission HCT of 35, what does that tell you? (It tells me that it is a normal value, and she is well set to handle a typical amount of blood loss for birth). If Queen Jones has an admission Hct of 28, that raises several concerns. Is it part of a larger picture like HELLP? Has she been losing blood somehow, like placental bleeding?
For this case: Lab value of ALT 70 and AST 90 show elevated liver enzymes. We have a low platelet count of 80,000. The significance of these numbers is: this indicates the patient has developed HELLP syndrome (Hemolysis, Elevated Liver Enzymes, Low Platelets). The low platelet count also increases risk of bleeding and, while you may not know this as a student, due to this risk of bleeding the patient typically cannot get regional anesthesia (epidural or spinal) with a platelet count below 75k-100k depending on facility protocol and provider comfort level.
WHAT IS THE DISEASE PROCESS CAUSING THESE ASSESSMENT FINDINGS (ANALYZE CUES)?
(Discuss pathophys in the DESCRIBE DISEASE PROCESS AFFECTING PATIENT (Include Pathophysiology of Disease Process) section
WHAT IS THE MAIN PROBLEM WITH THE PATIENT THE NURSE CAN TREAT (PRIORITIZE HYPOTHESES)? Another way to think of it is what do I as the nurse have control over?
This one is a bit tricky. You can’t really do anything about the fact that the patient has HELLP syndrome. What you can do is MANAGE RISK factors (hypertensive crisis, eclamptic seizures, falls, etc.) by:
Treating her with medication as ordered to control BP
Reducing risk of seizure by administering Magnesium sulfate as ordered, providing safety with padded rails, etc.
Lack of knowledge is a problem for all patients who need to learn about their disease process or condition. What should they alert the nurse/staff about? What do they need to do or avoid? What side effects could medication cause?
WHAT IS THE GOAL FOR THE PATIENT (GENERATE SOLUTIONS & TAKE ACTION)? CREATE SPECIFIC, MEASURABLE, ACHIEVABLE, REALISTIC, AND TIMETABLE (SMART) OUTCOMES.
Think safety. Think best outcome. For this patient that would be:
- Pt will remain free of injury (covers fall and seizure) by the end of shift.
- Pt will remain normotensive by end of shift
- Pt will have adequate urine output of 30ml/hr or more by end of shift
WHAT INTERVENTIONS WILL THE NURSE IMPLEMENT WHEN CARING FOR THIS PATIENT (GENERATE SOLUTIONS & TAKE ACTION)? INCLUDE THE EVIDENCE/(RATIONALE). LIST INTERVENTIONS IN ORDER OF PRIORITY. INCLUDE COLLABORATIVE AND NURSE‐INITIATED INTERVENTIONS
Evidence means citing where you got the knowledge from-your textbook? A website? An article?
What is the priority? Go back to RISK FACTORS/PROBLEMS
What is the worst-case scenario with elevated BP? >Stroke
So…we want to control patient’s blood pressure-how can nurses do this?
- Create a calm, quiet environment
- Have the patient rest in bed
- Monitor BP (and other vitals) hourly, or per protocol/orders
- Give blood pressure medication as ordered by provider, especially if patient becomes severely hypertensive (160/110) she will require additional prn IV med.
Rationale for controlling BP: Hypertension results from biochemical changes that cause vasoconstriction and vasospasm. A sharp increase in BP indicate progression of preeclampsia and increase risk of stroke.
What is the worst case scenario with Pre-Eclampsia? >That the patient become eclamptic (starts having seizures).
So, nurse will:
Monitor patient for worsening symptoms such as headache, visual changes, epigastric pain, hyperreflexia, presence of clonus. Monitor lab value trends regularly.
Educate patient to report new or worsening headache, visual changes, epigastric pain, and to call staff for assistance if getting out of bed.
Minimize the likelihood of seizure by giving a CNS depressant, Magnesium sulfate, as ordered.
We know that preeclampsia is a multi-organ disorder (pathophys). How do I know if her liver is OK? Lab values, absence of RUQ pain. How do I know if her kidneys are ok? Monitoring urine output and lab values for kidneys (proteinuria, creatinine, BUN, etc.)
Connect interventions to rationale, for example:
Monitor I&O per protocol (or provider orders). Rationale: Oliguria can indicate hypovolemia and renal hypoperfusion
How is the problem, the pre-eclampsia, affecting the unseen patient, the baby? How is the fetus tolerating being in the uterus right now? We need to see baby on the monitor to know that.
Intervention: Assess the fetal heart rate pattern with continuous monitoring. If there are signs of hypoxia, alert provider. (Would move to delivery)
Don’t forget about the emotional and psycho-social aspect, such as having this condition can cause anxiety.
Or with pre-term labor, patient could be experiencing anxiety about delivering early.
Patient (in any scenario) also needs knowledge about the healthcare team’s concerns and management plan. Intervention: Educate patient and family about …
Intervention: Prepare the patient and family for cesarean delivery if indicated due to the progression of preeclampsia or determined by the healthcare provider
Rationale: Fetal and placental delivery ceases the progression of preeclampsia. Failed induction and/or attempt for vaginal delivery will lead to cesarean section.
HOW WILL THE NURSE EVALUATE THE PATIENT’S RESPONSE (EVALUATE OUTCOMES)? AND WHAT WAS THE PATIENT’S RESPONSE TO THE INTERVENTIONS? Another way to think about it is, were the goals met in the time frame you specified? Then your interventions were effective!
Pt’s blood pressure remained less than 160/110 throughout the shift
Pt did not experience worsening HA, visual changes, or epigastric pain
DTR’s were within normal limits without change
Urine output adequate
Pt remained free of injury
Fetal tracing does not show signs of hypoxia
WHAT OTHER PROBLEMS COULD THE NURSE LINK TO THIS PATIENT PROBLEM?
I am not sure if what they are asking is what other health conditions could happen as a result of the patient having the main problem?
Pulmonary edema, Hypertensive crisis, Seizures (eclampsia), Retinal detachment, Stroke, Abruptio placentae, Thrombocytopenia, Acute renal failure, Preterm labor, Intrauterine growth restriction. (Lippincott Advisor Diseases and Conditions).
DESCRIBE DISEASE PROCESS AFFECTING PATIENT (Include Pathophysiology of Disease Process)
In preeclampsia and eclampsia, placental hypoperfusion, hypoxia, and ischemia develop due to: failure of maternal uterine spiral arteries to undergo remodeling in the first trimester; release of factors that affect maternal vascular endothelial function; systemic vasospasm; leukocyte activation; coagulation system activation. Talk about why patient would have edema, proteinuria, affects multiple organs, visual changes are due to retinal edema, etc. CONNECT pathophys to assessment findings/typical presentation with this condition/what you are watching out for
Kidney function test – urine protein 400mg. Cr 12 mg/dL.
• CBC – Platelet 80,000, Hgb 14 g/dl
• Liver function test – ALT 70 U/L, AST 90 U/L
In addition to tests already performed, what other tests do you think might be needed?
INCLUDING PRIORITY PATIENT PROBLEM(S)
· Pt is age 16 (why is that significant?
Adolescent developmental phase, need to understand care needs and how you would approach differently/teach differently).
· Pt has only her mom for support
· Pt is hypertensive with BP 150/80
· Diagnosed with pre-eclampsia (based on VS and diagnostic tests)
· She is under weight for her current gestation.
· Risk for seizure
Many of you listed data from the case study such as: BP 150/80 mm Hg, pedal edema, urine protein 400mg, Platelet 80,000, ALT 70 U/L, AST 90 U/L, Cr 12 mg/dL
These are not assessment findings, except the BP and pedal edema. This is data from the chart. How do you interpret what you find on physical exam and interviewing? Make the connection!
Assessment is lung sounds-crackles? Could indicate fluid overload. Deep Tendon Reflexes and Clonus-exaggerated reflexes or positive clonus? getting closer to seizing
RUQ pain? Liver is being affected by disease process
PLAN OF CARE/INTERVENTIONS
Another way to think of this is-what will I spend my shift doing? What am I most concerned about for this patient? How will I know if the patient’s condition is getting worse? What will I monitor? What risks will I work to avoid?
- Assess Vital Signs hourly per protocol/orders
- Assess DTR and clonus q 4 hours per protocol/orders
- Administer antihypertensives and magnesium sulfate as ordered
- Educate patient about symptoms to report
- Monitor I&O hourly (strict I and O)
- Monitor for worsening symptoms
- Continuous fetal monitoring
- Quiet room with dim lighting, safety….
What assessment data does the nurse find as pertinent (important) (recognize cues)?
Risk factors: Laticia Garcia, a 15-year-old female, has not received prenatal care due to pregnancy denial, current weight 158lbs, which is slightly lower, nulliparity, and sexually active.
Current problem: The patient complains of excruciating abdominal pain has a distended abdomen. Lab results includes Na: 142, K: 4.2, Plt: 265, Hgb: 13, Cl: 102, Mg: 1.2, and WBC: 5.2. The majority of the lab results are within the normal range, therefore eliminating the possibility of infections or systemic diseases. For example, WBC: 5.2 is within the normal range; therefore, it is unlikely that the patient has any infections. The Mg:1.2 is, however, slightly lower than the normal range of 1.8, which suggests the possibility of a health condition; however, since other parameters are within the normal range, it is less likely that the patient has an underlying condition. The distended abdomen and excruciating pain suggest the possibility of a pregnancy, which can explain the slightly lower mg levels since the patient has not had prenatal care (Liu & Zhang, 2021).
What is the disease process causing these assessment findings?
Full-term pregnancy: The primary diagnosis for this patient is a full-term pregnancy which is not a health condition; rather, it is a normal biological condition that results in the birth of a child. A full-term pregnancy is defined as a pregnancy where the baby is born between 39 weeks 0 days to 40 weeks 6 days. The excruciating abdominal pain experienced by the patient is labor pains. At the end of a pregnancy, uterus contractions occur to push the baby out, leading to pain as the muscles tighten. At the end of pregnancy, the body will start to produce hormones such as prostaglandin, which increases the sensitivity to other hormones. Oxytocin contributes to contractions that facilitate the expulsion of the fetus, relaxin, and Beta-endorphins facilitate stretching of the cervix and relief from pain, respectively (Tripp, 2021).
What is the main problem with the patient the nurse can treat?
Pain management relief measures will be necessary for this patient. The care provider should initiate natural pain relief measures such as patterned breathing, movement, and position changes. Medications can also be used to manage the pain. The patient is in denial of pregnancy; therefore, care provider should inform the patient and the family members of the pregnancy status and explain to the patient that she is pregnant and that it is due for delivery, which should explain the excruciating abdominal pain (Nanji & Carvalho, 2020).
What is the goal for the patient outcomes?
- The patient and the family members will be aware of her pregnancy status.
- The patient will experience pain relief during the delivery process.
- The patient will have a natural birth with minimal complications.
What interventions will the nurse implement when caring for this patient
- Assess the patient’s psychological readiness; it is important to ensure that the patient is psychologically aware and ready for the birth process, including the actions that are necessary to have a safe delivery, dangers and risks associated with the birth process, and the impact the delivery process will have on her physically and emotionally.
- Allow and encourage the patient to be active: research has shown that assuming upright positions during labor is effective in preventing complications associated with delivery.
- Assess the patient’s vital signs and those of the fetus; this will assist in detecting any abnormalities early enough to prevent complications.
- Conduct patient education on the delivery process and after delivery care practices; patient education will ensure that the patient is aware of the delivery process and can identify abnormalities such as excessive pain; it will also equip her with the necessary skills and knowledge to handle emergencies (Nanji & Carvalho, 2020).
How will the nurse evaluate the patient’s response?
- The patient will report a decreased level/severity of labor pains.
- The patient will exhibit increased awareness concerning her pregnancy and the necessary measures to be taken in the event of an emergency.
- The patient will maintain normal vital signs as well as the fetus.
What other problems could the nurse link to this patient problem?
Some of the conditions that can cause excruciating abdominal pain include organ rupture, including appendicitis, kidney stones and infections, irritable bowel syndrome, urinary tract infection, and intestinal obstruction.
Liu, G. L., & Zhang, N. Z. (2021). Routine blood tests in early pregnancy: their development and value in the early diagnosis of gestational diabetes mellitus. Clin. Exp. Obstet. Gynecol, 48(2), 228-233. http://venus-pro-bucket.s3.amazonaws.com/journal/CEOG/48/2/10.31083/j.ceog.2021.02.2273/CEOG2273.pdf
Nanji, J. A., & Carvalho, B. (2020). Pain management during labor and vaginal birth. Best Practice & Research Clinical Obstetrics & Gynaecology, 67, 100-112. https://www.sciencedirect.com/science/article/abs/pii/S1521693420300432
Tripp, R. (2021). Physiology of pregnancy. Emergency Medical Services: Clinical Practice and Systems Oversight, 1, 343-349. https://onlinelibrary.wiley.com/doi/abs/10.1002/9781119756279.ch41