Isbar Preeclampsia ATI PDF

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Summary

ATI Assignment for Maternal child nursing...

Description

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I-SBAR for Direct Patient Care Documentation Antepartum/Intrapartum

I

Introduce yourself

Sabrina Jacques Student Nurse

Your Name: Your Title:

Caring for KK D41102521

Reason for being there: D#: Patient Initials: KK EDC:

S

Situation

N/A

N/A

LMP:

X Singleton

Twin

Age: 25

1 0 0 0 0 G____T____P____A____L____

Other:

Gest. Age: 27

/7 weeks

Other

Reason for Admit: Headache, blurred vision, vomiting, nausea, and epigastric pain, urine protein +1, deep tendon reflexes 3+, HTN Fetal Movement: Active

X Present

Membrane Status: Intact Date: 05/02/xx

X Intact Fluid: N/A

Time: 1145

Not Present Ruptured

Previous Pregnancies: Year

B

Background

Type of Delivery

Labor Length

Complications

N/A N/A

Current Pregnancy – Prenatal Care: X Yes

GBS Status:

No

Labs: Blood tests, CMP, urinalysis, uric acid

Breast Feeding:

Preeclampsia

Complications:

Positive X Negative

Family Support:

Yes X No N/A

Past Medical History: N/A Home Medications: Prenatal vitamins Vital Signs Temp

A

Assessment

HR

RR

37.0 C

B/P 162/98

92

22

97%

8/10

140

37.0 C

160/100

100

24

97%

8/10

120

Labor status:

N/A

Onset:

Vaginal exam: N/A

/

Planned method of delivery:

N/A

/ Duration:

Pain

Stage/Phase: Blood/Fluid:

Emergency C-section

Contraction pattern: frequency: N/A Labor progress:

SP02

FHTS

N/A

N/A

Vaginal X C/Section N/A

Strength:N/A

N/A

Maternal physical assessment: DTR 3+, blurred vision, epigastric pain, Headache 8/10, edema of the face IV: Lactated ringers, Hydralazine, Magnesium Current meds: Magnesium sulfate 4g IV bolus, Hydralazine 5 mg IV bolus, calcium gluconate

R

Labs:

CBC, urinalysis, type and screen

Activity:

Strict bedrest

Discharge planning needs: pain management, limit ADL’s, education on premature birth and preeclampsia post delivery

Recommendation

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 28 | Chicago, IL 60661 12-200085.1

©2021 Chamberlain University LLC. All rights reserved.

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I-SBAR for Direct Patient Care Documentation Antepartum/Intrapartum

PLAN OF CARE: Risk for chronic hypertension related to severe preeclampsia antepartum

Nursing Analysis/Priority Diagnosis: Patient Goal:

Patient’s blood pressure will decrease to safe range by end of shift

Outcome Criteria: Met X Not met

Patient will show no evidence of pulmonary edema, facial edema will decrease, resume adequate urine output, and headache pain will subside

Partially met

Priority Interventions

Reasoning

1.

Edema, continuous headache, drowsiness, or mental confusion indicate poor cerebral perfusion and may be precursors of seizures. Visual disturbances such as blurred or double vision or spots before the eyes indicate arterial spasms and edema in the retina. epigastric pain or “upset stomach” are particularly ominous because they indicate distention of the hepatic capsule and increase the risk for liver rupture. Decreased urinary output indicates poor perfusion of the kidneys and may precede acute renal failure (Murray et. al, 2019).

Assess vital signs, conduct physical examination and daily weight monitoring.

2. Instruct patient to maintain bedrest and explain the need for little activity due to stress management and safety after medication administration. Explain the importance of side-lying position for uterine perfusion.

3. Administer anti-hypertensives and magnesium sulfate. Educate client on the purpose and side effects of each medication.

Antihypertensive therapies are reserved for women with systolic blood pressure 160 mm Hg or greater or diastolic blood pressure 110 mm Hg or greater to decrease the risk for stroke or congestive heart failure (CHF). Hydralazine (Apresoline)—Higher doses are associated with maternal hypotension, headaches, and fetal distress. Magnesium sulfate is the drug most often used to prevent seizures (Murray et. al, 2019).

Patient exhibited facial edema, reported a headache 8/10 as well as visual disturbances, and epigastric pain. BP was 162/98

Patient remained in bed, laid on each side, and verbally confirmed her understanding of the education.

! ! Patient tolerated both drugs relatively well. Blood pressure decreased slightly. Patient became slightly nauseated but emesis did not occur. Patient was educated on side effects and verbally confirmed understanding.

4. Prepare for immediate delivery of the fetus incase fetal distress and/or maternal decompensation occurs

5. Once baby is delivered, monitor for abnormalities and complications. RDS should be expected so prepare for neonatal resuscitation. Prepare NICU team. Monitor mother for seizures and continue to treat for preeclampsia until blood pressure returns to normal range and symptoms subsides.

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The lateral position decreases pressure on the vena cava, thereby increasing cardiac return and circulatory volume and improving perfusion of the woman’s vital organs and the placenta. Although the efficacy of bed rest is not clearly established, it remains a usual and reasonable recommendation for preeclampsia management (Murray et. al, 2019).

Evaluation of Intervention

The only “cure” for preeclampsia and eclampsia is delivery of the fetus. If the mother or fetus’s conditions get worse, immediate delivery is needed to preserve the lives of both mom and baby (Murray et. al, 2019).

Assessments for signs and symptoms of preeclampsia should be continued for at least 48 hours, administration of magnesium usually is continued to prevent seizures for 24 hours. Signs of recovery include: • Diuresis—Increased urinary output, which causes a rapid reduction in edema and rapid weight loss • Decreased protein in the urine • Return of blood pressure to normal • Resolution of abnormal laboratory values (Murray et. al, 2019

Fetal heart rate began to decline. Patient consented to emergency c-section in order to prevent further fetal decompensation.

Client resumed care and was monitored closely for the next 24 hours. Infant was transferred to NICU.

Chamberlain University | National Management Offices | 500 W. Monroe St., Suite 28 | Chicago, IL 60661 12-200085.1

©2021 Chamberlain University LLC. All rights reserved.

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References

Murray, S. S., McKinney, E.S., Holub, K.S., & Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). Elsevier.! ! ! ! ! ! ! ! ! !...