Preeclampsia CASE Study #1 PDF

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Preeclampsia case study...

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Preeclampsia-Eclampsia UNFOLDING Reasoning

Dana Myers, 40 years old

Primary Concept Intracranial Regulation

Interrelated Concepts (In order of emphasis) 1. Perfusion 2. Reproduction 3. Clinical Judgment 4. Patient Education 5. Communication 6. Collaboration

UNFOLDING Clinical Reasoning Case Study: STUDENT © 2016 Keith Rischer/www.KeithRN.com

Preeclampsia-Eclampsia History of Present Problem: Dana Myers is a 40-year-old woman, G-3 P-2 who is 34 weeks gestation. Her health care provider has been monitoring her weekly because her blood pressure has been increasing the past month and is currently 146/88. Last week she had 1+ non-pitting edema of both lower extremities (BLE) and her urine was negative for protein. Today during her clinic visit, Dana’s BP was 168/90. She had 2+ proteinuria and 3+ pitting edema BLE. She also complained of a mild headache in the center of her forehead, and seeing “spots.” Fetal heart tones via Doppler are 136/minute in the lower left quadrant. Abdominal measurement from pubic bone to top of fundus is 31 cm. The primary care provider was concerned and Dana has been admitted to the community hospital labor and delivery unit to be evaluated for severe preeclampsia. You are the admitting nurse responsible for her care.

Personal/Social History: Dana has two children, ages two and four. She is married and both she and her husband are excited to have another baby, but have been concerned about this pregnancy. Dana’s previous two pregnancies were healthy, without incident, resulting in the vaginal births of a boy, then a girl. Dana’s parents live in the same town and are supportive. Dana works part-time teaching English at the local community college. Her husband is an engineer who works full time and is occasionally out of town for work. Dana is generally healthy, without any chronic illnesses. She does not smoke or use recreational drugs. She reports drinking socially but refrains while pregnant. What data from the histories are RELEVANT and has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: 40 yrs old Advanced maternal age 146/88 and 168/90 High bp 2+ proteinuria s/s of preeclampsia Headache/Vision- seeing spots Fundus is 31cm normal FHR 136 normal Multiple preg 3+ pitting edema BLE worsening Clinical Significance: RELEVANT Data from Social History: Children 2 and 4 yrs old They depend on her; she is their caregiver. Married, parents close by Supportive 2 previous vaginal deliveries Vaginal Both parents work Financially stable, could be stressful

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medication treats which condition? Draw lines to connect.) PMH: Home Meds: Pharm. Classification: Expected Outcome:  Prenatal vitamins  G-3 P-2 Vitamins Healthy pregnancy, mom and baby 34 weeks gestation with no  Healthy chronic medical  conditions

Patient Care Begins: Current VS:

P-Q-R-S-T Pain Assessment (5th VS):

T: 98.4 F/36.9 C (oral)

Provoking/Palliative: None

© 2016 Keith Rischer/www.KeithRN.com

P: 84 (regular) R: 20 (regular) BP: 164/98 O2 sat: 95% room air

Quality: Region/Radiation: Severity: Timing:

Stabbing/throbbing Eyes, forehead 5/10 Constant, unrelieved by acetaminophen

What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: BP 164/98 Severe preeclampsia Pain in forehead Headache, blurry vision, s/s of preeclampsia

Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC:

NEURO:

GI: GU: SKIN:

Appears uncomfortable Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort Pink, warm/dry, 3+ non-pitting edema of BLEs with generalized edema of hands, face, and sacrum, heart sounds regular with no abnormal beats, equal with palpation at radial/pedal/post-tibial landmarks Alert and oriented to person, place, time, and situation (x4). Reflexes are brisk with no clonus, c/o headache and continues to see “spots”

Abdomen soft/non-tender, slight epigastric discomfort, bowel sounds audible per auscultation in all four quadrants, no contractions palpated, uterus soft. Voiding without difficulty, urine clear/yellow, urine 2+ by dipstick. Skin integrity intact

What assessment data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: Uncomfortable Something is wrong Vision/headache/3+ edema s/s preeclampsia epigastric edema/liver/kidney

Non-stress Test What results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Results: Clinical Significance: The non-stress test is Non-reactive, no acceleration/decelerations, FHR good nonreactive. Fetal heart rate baseline 130, with minimum variability and no accelerations. No decelerations are noted.

Lab Results: © 2016 Keith Rischer/www.KeithRN.com

Complete Blood Count (CBC:) WBC (4.5–11.0 mm 3) 5,000-15,000 Hgb (12–16 g/dL) Pregnancy: 11.5-14 Platelets (150-450 x103/µl) Neutrophil % (42–72)

Current: 14.8 11.3 72 70

High/Low/WNL? WNL LOW LOW WNL

Previous: 14.5 11.4 115 68

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: WBC HgB Platelets Neutrophils

Usually slightly elevated during pregnancy Low, anemia, PROM. Low., HELLP? WNL

Basic Metabolic Panel (BMP:) BUN: (7–25 mg/dl) Pregnant: (3-11mg/mL) Creatinine: (0.6–1.2 mg/dL) Pregnant: 0.4-0.9 mg/mL

Stable/worsening Worsening Worsening Stable

Current: 33

High/Low/WNL? HIGH

Previous: 11

2.1

HIGH

1.4

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Lab(s):

Clinical Significance:

TREND:

BUN Cr

Kidney damage High-Liver

Improve/Worsening/Stable: Worsening Worsening

Liver Function Test (LFT:) Albumin (3.5–5.5 g/dL) Total Bilirubin (0.1–1.0 mg/dL) Alkaline Phosphatase male:

Current: 4.5 0.5 122

High/Low/WNL? WNL WNL WNL

Previous: 4.7 0.6 90

20 18 98

WNL WNL WNL

18 20 90

38–126 U/l female: 70–230 U/l

ALT (8–20 U/L) AST (8–20 U/L) LDH (90-156 units/L)

© 2016 Keith Rischer/www.KeithRN.com

RELEVANT Lab(s): All within normal levels

Urine Analysis (UA:) PCR

Clinical Significance:

Current: 4.3

TREND: Improve/Worsening/Stable:

WNL/Abnormal? Abnormal

Previous: n/a

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

PCR

Proteinuria

Worsening

Clinical Reasoning Begins… 1.

What is the primary problem that your patient is most likely presenting?

Preeclampsia Triad- HTN, proteinuria, edema What is the underlying cause/pathophysiology of this primary problem? (Relate initial manifestations to the pathophysiology of the primary problem) Pathophysiology of Primary Problem: Rationale for Manifestations: 2.

Severe Preeclampsia

© 2016 Keith Rischer/www.KeithRN.com

High BP, High BUN/Cr, proteinuria, edema

Collaborative Care: Medical Management Care Provider Orders: Labetolol 20 mg IV x1

Rationale:

Expected Outcome:

Beta Blocker, antihypertensive (watch HR)

Lower BP

Magnesium sulfate 4 g IV bolus (40 g in 1000 mL LR) followed by continuous IV infusion at 2 g/hour

Seizure prevention, renal insufficiency, Order calcium gluconate for antidote

Lower BP, no seizures

Fetal lung development/maturity. Corticosteroid

Baby will not be hypoxic

Induce labor contractions.

Give birth

Make sure FHR is stable

Baby is stable

Have O2 ready

Safety

Betamethasone 12 mg IM

Prepare for induction of labor

Continuous fetal monitoring

Seizure precautions

PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Order of Priority: Rationale: • Seizure precautions 1. Seizure Safety to prevent inuries • Labetalol 20 mg IV x1 precautions now 2. Labetalol Lower BP • Magnesium sulfate 4 g 3. Betamethasone Needs time to work, improve baby’s lungs. IV bolus (40 g in 1000 Prevent seizures. 4. Magnesium mL LR) followed by Always monitor! 5. Continue to continuous IV infusion monitor FHR at 2 g/hour • •

Continuous fetal monitoring Betamethasone 12 mg IM

Medication Dosage Calculation: Medication/Dose:

Mechanism of Action:

© 2016 Keith Rischer/www.KeithRN.com

Volume/time frame to Safely Administer:

Nursing Assessment/Considerations:

Magnesium sulfate

Prevent seizures Lower BP

(40 g in 1000 mL LR) infuse at

2 g/hour

IV Bolus: 4g

Seizure precautions/Lower BP Assess: RR, urine output, DTR, clonus every hour, CNS depression

IV Infusion: 2 g/hour

Collaborative Care: Nursing 3.

What nursing priority (ies) will guide your plan of care? (if more than one-list in order of PRIORITY) Stabilize mom by decreasing BP, reduce the stimuli (lights, noise, visitors), monitor FHR

4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale:

Expected Outcome:

Monitor VS every 15 min (BP, HR, RR) labs and LOC

Moms BP will decrease

Safety of mom and baby

Limit visitors, reduce noise, dim lights, fan Decrease risk of seizure

No fetal distress

Lay on left side

No seizures for mom

5.

Better perfusion

What body system(s) will you assess most thoroughly based on the primary/priority concern?

Central Nervous System- seizure, stroke. Renal-kidneys 6.

What is the worst possible/most likely complication to anticipate?

Mom and baby could die- stroke, hemorrhage during birth, baby hypoxic

7.

What nursing assessments will identify this complication EARLY if it develops?

Monitor vital signs continuously on mom and baby. Watch and understand labs

8.

What nursing interventions will you initiate if this complication develops?

Hemorrhage- know moms blood type, type and cross Hypoxic baby- have o2 ready

© 2016 Keith Rischer/www.KeithRN.com

9.

What psychosocial needs will this patient and/or family likely have that will need to be addressed?

Very scared and worried. They will most likely have questions

10. How can the nurse address these psychosocial needs?

Tell patient of possible complications, preventative measures, medications, continuous monitoring, Reassure her she is in good hands and will be taken care of.

Evaluation: Evaluate the response of your patient to nursing and medical interventions during your shift. All physician orders have been implemented that are listed under medical management.

Current VS:

Most Recent:

T: 98.6 F/37 C (oral) P: 74 (regular) R: 12 (regular) BP: 158/90 O2 sat: 96% room air

T: 98.4 F/36.9 C (oral) P: 84 (regular) R: 20 (regular) BP: 164/98 O2 sat: 95% room air

Current PQRST: Provoking/Palliative: Quality: Region/Radiation: Severity: Timing:

Unable to verbalize

Current Assessment: GENERAL Lethargic, difficult to arouse APPEARANCE: RESP: Breath sounds clear with equal aeration bilaterally, slowed-shallow respiratory effort CARDIAC: Pink, warm/dry, no edema, heart sounds regular with no abnormal beats, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Not oriented, lethargic, not able to move her arms and legs

GI: GU: SKIN:

Abdomen soft/non-tender, bowel sounds audible per auscultation in all four quadrants Voiding without difficulty, urine clear/yellow Skin integrity intact

1. What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: Low RR/shallow Respiratory rate is 12

Pain

Unable to verbalize

RELEVANT Assessment Data:

Clinical Significance:

Lethargic/difficult to arouse

Mag Toxicity

Not oriented/cant move extremities

Hyporeflexia

© 2016 Keith Rischer/www.KeithRN.com

2.

Has the status improved or not as expected to this point?

Not improved/declining 3.

Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?

Yes, D/C magnesium

4.

Based on your current evaluation, what are your nursing priorities and plan of care?

D/C mag- call provider (Calcium Gluconate)

It is now the end of your shift. Effective and concise handoffs are essential to excellent care and, if not done well, can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be caring for this patient:

Situation: Name/age: Dana Myers, 40 years old BRIEF summary of primary problem: Dana is 34 wks gestation presenting with severe preeclampsia. Magnesium sulfate was started. Pt is starting to have mag toxicity. Mag D/C’d. Day of admission/post-op #: 1

Background: Primary problem/diagnosis:

Possible magnesium toxicity.

Assessment: Vital signs:

T: 98.6, P:74, RR: 12, BP: 158/90, O2: 96 RA, Pain: unable to verbalize RELEVANT body system nursing assessment data:

Lethargic, not oriented, cannot mover her extremities, slowed shallow respiratory effort,

Recommendation: Suggestions: Give Calcium Gluconate

The primary care provider gives you the following TORB (telephone order read back) orders: Medical Management: Rationale for Treatment and Expected Outcomes Care Provider Orders: Stop Magnesium sulfate infusion

Rationale:

Expected Outcome:

Mag Toxicity

Reverse and lower mag level

Calcium gluconate 1 g IV push

Antidote for Mag

“

© 2016 Keith Rischer/www.KeithRN.com

Stat magnesium level and one hour after calcium gluconate infusion

See toxicity level

Lactated Ringers (LR) 125 mL/hour IV infusion

Flush out mag

“ “

All orders have been initiated and the following lab results are obtained: Misc. Labs: Magnesium (1.6–2.0 mEq/L)

RELEVANT Lab(s): Mag 2.4

Current: 2.4

High/Low/WNL? High

Clinical Significance: It is lowering

Previous: 3.9

TREND: Improve/Worsening/Stable: Improving

Evaluation: One hour later… One hour after receiving calcium gluconate IV, the nurse collects the following assessment data: Current VS: Most Recent: Current PQRST: T: 98.6 F/37 C (oral) T: 98.6 F/37 C (oral) Provoking/Palliative: Denies P: 88 (regular) P: 74 (regular) Quality: R: 18 (regular) R: 12 (regular) Region/Radiation: BP: 162/92 BP: 158/90 Severity: O2 sat: 96% room air O2 sat: 96% room air Timing: Current Assessment: GENERAL Appears to be resting comfortably, awake APPEARANCE: RESP: Breath sounds clear with equal aeration bilaterally, regular non-labored respiratory effort CARDIAC: Pink, warm/dry, no edema, heart sounds regular with no abnormal beats, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert and oriented x4, is now able to move her arms and legs, reflexes are +2 without clonus.

GI: GU: SKIN:

Abdomen soft/non-tender, bowel sounds audible per auscultation in all four quadrants Voiding without difficulty, urine clear/yellow, output 100 ml in 3 hours Skin integrity intact

What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance:

BP 162/92

Still increased

Denies Pain

Improving

© 2016 Keith Rischer/www.KeithRN.com

RELEVANT Assessment Data: 2+ reflexes without clonus

Clinical Significance:

Oriented x4

1. Has the status improved or not as expected to this point? Yes, no headache. Vision back to normal but BP is still high 2. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? No. Patient is improving. .

3. Based on your current evaluation, what are your nursing priorities and plan of care?

Pt is stable and able to discharge.

It is now the end of your shift. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be caring for this patient:

Situation: Name/age: Dana Myers, 40 years old BRIEF summary of primary problem: Dana is 34 weeks pregnant who presented with severe preeclampsia. Pt was given mag. Had mag toxicity. Given calcium gluconate. Pt is stable and able to discharge.

Background: Primary problem/diagnosis:

Severe Preeclampsia RELEVANT past medical history: 2 previous vaginal births- no complications RELEVANT background data: Lives at home with husband, 2 children, parents are a huge support system

Assessment: © 2016 Keith Rischer/www.KeithRN.com

Vital signs: All vital signs stable with the exception if BP of 158/90

RELEVANT body system nursing assessment data: Alert and oriented x4, reflexes 2+ without clonus, voiding 100ml in 3 hours. RELEVANT lab values: Recheck mag level INTERPRETATION of current clinical status (stable/unstable/worsening):

Stable

Recommendation: Suggestions:

Pt is stable and able to D/C.

Education Priorities/Discharge Planning 1. What will be the most important discharge/education priorities you will reinforce with her medical condition to prevent future readmission with the same problem?

Vision changes, headache, swelling, bedrest, reduce stimuli, avoid foods with sodium, no alcohol, limit caffeine, drink water 2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient? Teach back method- they explain back to you what you taught them Ask a question “When do you need to come back? Or when to call your doctor?”

Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation?

Nervous, worried, shocked. Her previous deliveries were very smooth, so this is scary to her. Pain, discomfort

2. What can you do to engage yourself with this patient’s experience, and show that he/she matter to you as a person?

Educating her. Talking with her and letting her know what is going on. Monitoring closely. Communic...