OLD DOMINION UNIVERSITY - Jamie Martin Miller's Nursing ...



Clinical Case Study of a Childbearing Family

Jamie L. Martin

UIN 00918554

Submitted in partial fulfillment of the requirements in the course

NURS 331: Clinical Management: Childbearing Family

Old Dominion University

NORFOLK, VIRGINIA

Fall, 2012

This case study is an extensive analysis of the pregnancy of a teenage mother, S.Y., who gave birth to a male infant at a Norfolk, VA, area hospital in October 2012. This assessment includes an examination of the patient’s intrapartal and postpartal procedures, as well as a case analysis for nursing care based on the Association of Women’s Health, Obstetric and Neonatal Nurses’ (AWHONN) standards. To better understand the prognosis, the patient’s pathophysiology, presenting symptoms and treatments will also be discussed.

Patient S.Y., a G1T0P0A0L1, is a 19 year old African American female who was admitted to the hospital at 40 weeks, 3 days gestation with complaints of contractions. She chose a selective induction with the medication Cytotec. She failed to progress at 7 cm so a cesarean section was performed. There were no complications, and the patient tolerated the procedure well. The baby weighed 7 lbs, 1oz and his height was 19.3 inches. S.Y. has a history of depression, but states she stopped taking her medication (Prozac) during her pregnancy. S.Y. is a former smoker, but does not currently use tobacco or alcohol. There was initial concern about intrauterine growth restriction (IUGR), but the issue resolved itself later in the pregnancy, according to the patient.

Intrapartal Procedures

S.Y. was admitted to the labor and delivery floor of the hospital for induction of labor with Cytotec and anticipated vaginal delivery. She had artificial rupture of membranes (AROM) and was put on pitocin via continuous intravenous (IV) infusion by way of a right peripheral port to further progress contractions. Admission fetal heart rate showed 140 beats per minute (bpm). The baby demonstrated variability of 6 to 25 bpm with positive accelerations and no decelerations. After expressing pain with contractions, S.Y. chose to receive the medication Duramorph via epidural and a foley catheter was inserted. At 7 cm of cervical dilation, S.Y. failed to progress as expected so she chose to have cesarean section based on her doctor’s recommendation. S.Y. was prepped for surgery and transported to the operating room for the procedure. After epidural anesthesia was administered, the doctor made a Pfannenstiel incision and the baby was delivered at 1721 in the vertex position. The Apgar score was 8 at 1 minute and 9 at five minutes. The placenta was removed with fundal massage, and the uterus was then cleared of clots and debris. The estimated blood loss was 1,000 ml and the Foley urinary output was 100 ml and clear. One thousand millileters of lactated ringers was administered intravenously for fluid replacement. S.Y. was determined to be hemodynamically stable following surgery, but was given Cytotec rectally as a prophylactic treatment to prevent postpartum hemorrhage. The baby was sent to the newborn nursery for a newborn assessment, and S.Y. was transferred to a recovery area and then postpartum care.

Postpartal Procedures

Approximately 24 hours post surgery, S.Y.’s Foley catheter was removed as well as her peripheral IV. Respiratory status is of primary concern after cesarean section due to the anesthesia and narcotics used, so vital signs were frequently taken. Bowel sounds and urinary status were also monitored due to the recent abdominal surgery. The incision site, lochia and body temperature were assessed for signs of bleeding or infection. The fundus was palpated for firmness to ensure no uterine bleeding or infection has occurred. Bloodwork was frequently drawn to assess for changes, particularly in hematocrit, hemoglobin and white blood cell counts.

Abdominal surgery, such as a cesarean section, is accompanied by high pain levels and, as a result, immobility. Certain precautions were taken to ensure S.Y. did not suffer from deep vein thrombosis, pulmonary embolism, hemorrhage or urinary and bowel retention, as a result of this immobility. S.Y. was encouraged to get out of bed and walk around her room 24 hours after the surgery. She was also encouraged to use her incentive spirometer 4 to 5 times per day. S.Y. experienced some dizziness when sitting up so she was encouraged to dangle her legs on the side of the bed before trying to ambulate. This frequent ambulation helped to ease some of the abdominal cramping and nausea caused by trapped gas.

To ease the post-surgical pain, Percocet was administered as every 4 hours as requested. However, this medication made S.Y. drowsy so the nurse also encouraged alternative pain relief methods such as splinting the incision while changing positions, coughing or deep breathing. The nurse also encouraged energy conservation techniques, such as sleeping while the baby is sleeping and taking frequent rest breaks, to allow the patient time to heal and recover from surgery. Tucks pads were encouraged to ease pain in the peritoneal area.

Breastfeeding proved difficult for S.Y. so a lactation consultant counseled her on how to obtain the correct latch and maintain it. The consultant showed S.Y. how to sit in a comfortable position as well as how to hold the baby while breastfeeding, particularly the football hold. The baby was not fully latching on S.Y.’s breast so breastfeeding was causing her some pain. The lactation consultant showed S.Y. how to keep the baby stimulated and keep his mouth wide enough to obtain a correct latch. S.Y. was supplementing breast milk with formula so the nurse focused her efforts on educating her on the benefits of breastfeeding, including weight loss, monetary savings, enhanced nutrition and immunologic function. The nurse encouraged S.Y. to breastfeed on each nipple for 15 minutes every two hours to promote optimum nutrition, as well as promote bonding between mom and baby. By teaching S.Y., a young mother, how to care for her baby, diaper changing and breastfeeding for example, this encouraged S.Y. to take on some of these self-care tasks early in the postpartum period.

Case Analysis

According to the seventh edition AWHONN standards of care, the care of S.Y. conforms to assessment, diagnosis, implementation and health teaching. However, her care did not meet the standards for collaboration and communication.

The healthcare team met the standard for assessment (I) by gathering a complete health history, including the patient’s medical and social history as well as her gynecological history. For example, her history of chlamydia, depression disorder diagnosed at age 13, and family history of coronary artery disease (mother) were noted in her chart. Additionally, a social worker included an in-depth social assessment that included a description of the patient’s support system, which included her mother and the father of the baby (her boyfriend). The patient’s physical intrapartam assessment included fetal heart rate (FHR) monitoring, vital signs, cervical dilation and pain level. Postpartum assessments included the BUBBLE-HE assessment, which included assessment of vital signs, breasts, uterus, bladder, bowel, lochia, perineum, lower extremities and emotional status.

The healthcare team met the standard for diagnosis (II) by choosing to perform a cesarean section on the patient after she failed to progress at 7 cm cervical dilation. The FHR baseline was 140 and within normal limits with good variability and no decelerations. The mother’s vital signs were also within normal limits. However, after several hours, with no further dilation past 7 cm, the doctor determined the mother’s contractions were insufficient and recommended a cesarean section. In order to make this determination, the doctor assessed the frequency and strength of contractions. AROM had been performed in the first stage of labor.

The healthcare team met the implementation standard (V) by performing induction of labor, AROM, and the cesarean section to ensure the baby’s safe delivery. After induction of epidural anesthesia, the patient was draped and cleaned for the cesarean section. A Pfannenstiel incision was made, and the baby was delivered safely in the vertex position. Throughout the labor process, the patient’s pain and comfort was assessed and addressed with pain medication, IV fluids and administration of oxygen.

The standard Coordination of Care (V) was met intrapartally through communication among the doctors, nurses and anesthesiologists to accomplish a safe cesarean section. The baby was also sent right away to the newborn nursery for his assessment while the mother was sent to postpartum care. However, postpartum care was not very succinct in regards to the patient teaching. The patient was struggling a great deal with breastfeeding, yet the primary nurse did not call on the lactation consultants to help her. The student nurse made the request for the lactation consultants. Additionally, the patient was having perineal pain, but was unaware that she could use Tucks pads to soothe the pain. She also had not been taught about the benefits of using a peri bottle to cleanse her vaginal/perineal area.

The standard of teaching (V) was met through the efforts of the lactation consultant, student nurse and nursing instructor. The student nurse and nursing instructor taught the patient the benefits of breastfeeding, including its weight loss and immune function benefits. But, the patient still seemed discouraged because the baby was hurting her nipples and did not seem to be getting enough milk. The student nurse made the lactation consultant aware of the patient’s deficit. She taught the patient how to get the baby to latch correctly and keep him from getting distracted. As a result of the lactation consultant’s efforts, the baby breastfed for approximately 15 minutes on each breast. The student nurse and nursing instructor also taught the patient the benefits of using Tucks pads and a peri bottle.

Lastly, the standard of evaluation (VI) was met by continually assessing the patient postpartum. Her lab values were monitored, namely her hematocrit, hemoglobin, red and white blood cell counts, and BUN and creatinine levels. The patient’s vitals signs were take every four hours to detect changes in her condition. The findings of the BUBBLE-HE assessment served as further evidence of the patient’s condition.

Prioritized Nursing Diagnoses

The nursing diagnoses for patient S.Y. are prioritized as follows: Acute pain related to recent abdominal surgery, deficient knowledge related to breastfeeding, and risk for ineffective coping related to previous depressive symptoms. Based on these diagnoses, outcomes, interventions with corresponding rationales, and evaluations are indentified to formulate a nursing plan of care.

Acute pain related to recent abdominal surgery

The priority diagnosis—acute pain related to recent abdominal surgery—was evidenced by the patient’s complaints of pain at level 6 or higher in the postpartum period. Additionally, she expressed pain with movement. This pain affected the patient’s ability to breastfeed and care for her baby. Expected outcomes include the patient stating her pain at less than 3 on the zero to ten pain scale rating. Further, the patient uses medications to decrease pain, and expresses pain relief as evidenced by vital signs within normal limits. Nursing interventions to alleviate this pain include assessing the location, quality, onset, frequency, duration, and pain scale rating. Pain relief will better enable the mother to care for her infant and breastfeed (Karlström, Engström-Olofsson, Norbergh, Sjoling, & Hildingsson, 2007). Evaluation: The patient will express that she has pain between zero and three on the pain scale while breastfeeding or taking care of the baby before disharge. Next, the nurse will administer analgesics or have the patient self-administer oral analgesia in order to increase participation and self-control in pain relief (Karlström, Engström-Olofsson, Norbergh, Sjoling, & Hildingsson, 2007). Evaluation: The patient will express pain relief and positive attitude before discharge. Lastly, the nurse will teach the patient about expected pain control postpartum. Karlström, Engström-Olofsson, Norbergh, Sjoling, & Hildingsson (2007) assert the women’s expectations are related to her perceived level of pain. Evaluation: the patient will verbalize understanding of expectations following teaching.

Deficient knowledge related to breastfeeding

The patient also expressed deficient knowledge related to breastfeeding as evidenced by her looks of exasperation and statements, such as “breastfeeding is hard,” during attempted feedings. It follows, from the before listed interventions, that the nurse will administer analgesics for pain relief. Patients who have minimal pain are more likely to be successful with breastfeeding. Evaluation: The patient will not complain of pain while breastfeeding. Next, the nurse will carefully monitor the progress of breastfeeding in mother and child (Davidson, London & Ladewig, 2012). Evaluation: The nurse notes signs of active feeding and increase in infant’s weight from previous assessment before discharge. Then, the nurse should encourage early and frequent skin-to-skin contact (SSC) between mother and child. SSC is simply when the infant is placed between the mother’s breasts in only a diaper so that mother and baby’s skin are touching (Bigelow, Power, Maclellan-Peters, Alex, & Mcdonald, 2012). A 2011 study showed that infants born by cesarean section who had early SSC had higher breastfeeding rates than those that did not. SSC provides warmth and stimulation for mother and child (Bigelow, Power, Maclellan-Peters, Alex, & Mcdonald, 2012). Evaluation: The patient engages in SSC at least six hours per day.

Risk for ineffective coping

The patient is at risk for ineffective coping related to pre-pregnancy bouts of depression as well as inadequate available resources. Nursing interventions include assessing the patient resources and support system available. Patients may not have adequate support when they return home from the hospital so it is important to learn about significant others, health care providers, community resources and spiritual counseling (Gulanick & Myers, 2011). Evaluation: The patient discusses her at-home resources. Next, as in breastfeeding, the nurse will initiate early SSC with mother and baby. SSC may decrease depression and stress by empowering women in their maternal role (Bigelow, Power, Maclellan-Peters, Alex, & Mcdonald, 2012). Lastly, the nurse will educate the patient on the postpartum experience, including changes in their physical, emotional and social life. Studies show that women who were adequately prepared for the postpartum experience reported less depressive symptoms than those that did not receive preparation (Howell, Mora, Chassin, & Leventhal, 2010). Evaluation: The patient will report that she feels adequately prepared for the postpartum experience prior to discharge.

Current Literature

Two current nursing journal articles, one clinical and one experimental, were identified to support interventions for the patient’s nursing diagnosis. The first experimental study, Effect of Mother/Infant Skin-to-Skin Contact on Postpartum Depressive Symptoms and Maternal Physiolgoical Stress, investigated the effects of SSC on postpartum depressive symptoms, as well as maternal physiological stress, in a sample of 30 mothers with full-term infants (Bigelow, Power, Maclellan-Peters, Alex, & Mcdonald, 2012). These 30 mothers engaged in SSC for approximately five hours per day in the infants’ first week of life and then two hours per day in the following month. The control group of sixty mothers provided little or no SSC to their infants. Mothers used a self-reported depression scale to measure depressive symptoms. The results reveals that mothers who engaged in SSC has less depressive symptoms in the first week and month of the infants’ lives than mothers who did not do SSC. Further, the researches conclude that SSC does benefit mothers by reducing depressive symptoms and stress in the postpartum period.

The second clinical nursing research article, Postoperative Pain After Cesarean Birth Affects Breastfeeding and Infant Care, studies women’s experience with postoperative pain and pain relief after a cesarean section (Karlström, Engström-Olofsson, Norbergh, Sjoling, & Hildingsson, 2007). Researchers used a descriptive patient survey to collect data in conjunction with a Visual Analog Scale and seven-point Likert scale to measure women’s birth experience. The sample consisted of 60 women in a Swedish hospital. The study found that the women’s risk of having a negative birthing experience was 80 percent higher for women having an emergency cesarean section. Even more the study found a negative relationship with postoperative pain and breasfeeding (e.g. high postoperative pain was associated with lower incidence of breastfeeding). The researchers concluded that there is a need for postoperative pain management for women who undergo cesarean section because it negatively impacts early infant care and breastfeeding.

Risk Factor Identification and Pathophysiology

Patient S.Y. is at risk for developing postpartum depression (PPD) because of her past history of depression. She was diagnosed with depression at age 13 and began taking Prozac shortly thereafter. Postpartum depression is a moderate to severe mood disorder that can be compared to a major depressive episode in the DSM-IV-TR (Corwin & Pajer, 2008). PDD is characterized by “sadness, an inability to take pleasure in most activities, anxiety, irritability, fatigue, poor sleep and recurrent thoughts of suicide and death” (Corwin & Pajer, p. 1530, 2008). PPD usually occurs within four weeks of childbirth, and Varcarolis and Halter (2010) point out that some psychotic features (e.g. delusional thoughts about infant) may accompany depressive feelings. This puts the baby at great risk. Postpartum depression is often accompanied by irritability and hostility, particularly toward the newborn (Davidson, London & Ladewig, 2012).

To understand PPD, it is necessary to view it as a subtype of major depressive disorder (MDD). MDD is primarily caused by the dysregulation of the neurochemical and neurendocrine body systems. Neurochemically, deficits of norepinephrine, dopamine, and/or serotonin in the brain, as well as deficits of monoamines, cause depression (McCance & Huether, 2010). In regards to the neuroendocrine system, the “excessive activation” of the hypothalamic-pituitary-adrenal system plays a role in the pathophysiology of depression (McCance & Huether, p. 653, 2010). Inflammation also seems to play a role in depression, particularly PPD. Pregnancy produces a heightened inflammatory response due to perineal tissue injury, uterine involution, pain, physical exertion and emotional stress (Corwin & Pajer, 2008). Women who have experienced a difficult or lengthy birth, or even a surgical cesarean section, may experience more inflammation than the typical pregnant women. Due to this heightened inflammation, these women are at greater risk for PPD, Corwin and Pajer (2008) assert.

The Beck Depression Inventory or Edinburg Postnatal Depression Scale (EPDS) are often used to screen women for PPD. For EPDS, a score of 12 or greater is diagnostic of depression (London & Ladewig, 2012). A healthcare provider will also conduct an in-depth interview to assess the severity of the disorder.

Presenting Symptoms of Risk Factor

S.Y. reported frequent episodes of crying during her pregnancy. Although she seemed jovial during her postpartum period, she seemed very timid when handling the baby. Her young age may play a role in her hesitant attitude. During an assessment by a social worker, the patient stated that she had no current mental health concerns. Although she appeared enthusiastic and receptive to neonatal education at times, she slept frequently and sent the baby back to the nursery so she could rest. Additionlly, S.Y.’s age, primiparity, low socioecomonic status and previous history of depression all put her at risk of PPD.

Treatments

There are interventions that can immediately benefit the woman at risk for PPD. As referenced earlier, the nurse should educate the woman on the postpartum experience. This should include the immediate physical consequences of childbirth, postsurgical pain relief, and neonatal care, just to name a few. This education will improve the woman’s postpartum experience by setting realistic expectations and reducing anxiety, which can lead to depressive symptoms (Howell, Mora, Chassin, & Leventhal, 2010).

The most important treatment for a woman at risk for PPD is frequent assessment and screening. The patient should be in frequent contact with a healthcare provider she trusts. Davidson, London & Ladewig (2012) recommend that at-risk women should receive a telephone patient call from a healthcare provider to follow-up right after delivery, and a clinic appointment should be scheduled in less than six weeks. Nurses are in a prime position to follow-up with these at-risk women. In these assessments, the woman’s social support should be identified because lack of social support puts them at risk for PPD.

If a woman is diagnosed with PPD, the woman and her children’s safety is priority (London & Ladewig, 2012). The healthcare provider must find out if the extent of the woman’s suicidal thoughts, hallucinations, delusions, or impulsiveness. Suicidal thoughts are particularly important to observe if the woman begins to show signs of improvement. London and Ladewig (2012) explain that women are at most risk when they enter and exit the depressed state. The nurse should be aware of these sensitive time frames when assessing the patient. Specifically, the nurse should ask the patient is she has a plan for suicide knowing that the presence of a plan puts the patient at great risk. The nurse should also educate the patient and her family about PPD and its progression. Treatment plans usually focus on psychotherapy and antidepressant medications for treatment. The nurse should educate the woman about the possible side effects of antidepressants, including sexual dysfunction, sleep disturbances, headache, nausea, diarrhea and anxiety (London & Ladewig, 2012). Additionally, breastfeeding should be continued with caution because antidepressants can be excreted in breastmilk and may have adverse effects on the baby’s cognitive functioning (Bigelow, Power, Maclellan-Peters, Alex, & Mcdonald, 2012). Lastly, the nurse should direct the patient to online resources as well as support groups where she may find the support of other mothers enduring the same symptoms.

Conclusion

In-depth patient case studies, such as this one, allow the nurse to more fully understand and empathize with the childbearing family. In a state of emotional change and flux, the new mother is in particular need of emotional support and proactive nursing care. It is therefore of great importance that nurses pay attention to their patients’ risk factors. In this case, the patient’s previous history of depression, age, and socioeconomic status, among other things, put her at great risk for PPD. Awareness is the first toward prevention, and the nurse can use this awareness in planning, assessing and evaluating the patient’s care. Sometimes the excitement of birth can mask an underlying problem that may surface long after birth. It is the nurse’s role as a patient advocate to identify these problems before they occur.

References

Association of Women’s Health, Obstetric and Neonatal Nurses. (2009). Standards for professional nursing practice in the care of women and newborns (7th ed.). Washington, DC: Author.

Berg, O., & Hung, K. J. (2011). Early Skin-to-Skin to Improve Breastfeeding After Cesarean Birth. JOGNN: Journal Of Obstetric, Gynecologic & Neonatal Nursing, 40S18-S19. doi:10.1111/j.1552-6909.2011.01242_24.x

Bigelow, A., Power, M., Maclellan-Peters, J., Alex, M., & Mcdonald, C. (2012). Effect of Mother/Infant Skin-to-Skin Contact on Postpartum Depressive Symptoms and Maternal Physiological Stress. JOGNN: Journal Of Obstetric, Gynecologic & Neonatal Nursing, 41(3), 369-382. doi:10.1111/j.1552-6909.2012.01350.x

Corwin, E. J., & Pajer, K. (2008). The Psychoneuroimmunology of Postpartum Depression. Journal Of Women's Health (15409996), 17(9), 1529-1534. doi:10.1089/jwh.2007.0725

Howell, E. A., Mora, P. A., Chassin, M. R., & Leventhal, H. (2010). Lack of Preparation, Physical Health After Childbirth, and Early Postpartum Depressive Symptoms. Journal Of Women's Health (15409996), 19(4), 703-708. doi:10.1089/jwh.2008.1338

Karlström, A., Engström-Olofsson, R., Norbergh, K., Sjoling, M., & Hildingsson, I. (2007). Postoperative Pain After Cesarean Birth Affects Breastfeeding and Infant Care. JOGNN: Journal Of Obstetric, Gynecologic & Neonatal Nursing, 36(5), 430-440. doi:10.1111/j.1552-6909.2007.00160.x

Davidson, M., London, M., & Ladewig, P. (2012). Olds' Maternal-Newborn nursing & women's

health, across the lifespan, (9th ed.). Upper Saddle River, NJ: Pearson Education.

McCance, K. & Huether, S. (2010). Pathophysiology: The biologic basis for disease in adults

and children. (6th ed.). Philadelphia: Mosby.

Clinical Case Study Grading Rubric

|Grading Criteria |Point Value |Points |Comments |

|(Use these as your headings) | |Given | |

|Introduction |5 | | |

|Purpose of Assignment | | | |

|Brief Patient Background | | | |

|Reason for Admission | | | |

|Intrapartal Procedures |10 | | |

| | | | |

|Discuss any invasive or non-invasive procedures | | | |

|during the intrapartum period such as: | | | |

|AROM/SROM/Amnioinfusion/ | | | |

|Significant Lab Values/IV access/Fluid | | | |

|Maintenance/Fluid Bolus/Epidural/Foley/Oxygen/ | | | |

|Position Changes/ Episiotomy/ Comfort Measures/ | | | |

|Teaching/ Focused assessments to include baseline| | | |

|FHR with periodic changes (accels/decels); | | | |

|contraction frequency/intensity; labor progress | | | |

|through first stage with phases/second | | | |

|stage/third stage. | | | |

|Postpartal Procedures |10 | | |

| | | | |

|Discuss any invasive or non-invasive procedures | | | |

|during the postpartum period such as: | | | |

|Fundal Massage/Fluid Maintenance/Foley/Episotomy | | | |

|or LacerationRepair/Focused | | | |

|Assessments/Hemorrhage control/ Promotion of | | | |

|Maternal and Newborn Bonding/ Teaching/ Comfort | | | |

|Measures/ Promotion of Breastfeeding | | | |

|Case Analysis |20 | | |

| | | | |

|Does the care provided conform to the current | | | |

|standards of care? Why or why not? Were the | | | |

|client’s needs met? Do not restate the AWHONN | | | |

|standards but identify specific examples of how | | | |

|the standard was met. You must cite AWHONN | | | |

|Standards of Care in your Bibliography. Look up | | | |

|APA format for this as there is no author. | | | |

| | | | |

|Identify and prioritize at least 3 nursing | | | |

|diagnoses. | | | |

| | | | |

|Include contributing factors and evidence to | | | |

|support, nursing interventions and outcomes/with | | | |

|evaluation. | | | |

|Current Literature |10 | | |

| | | | |

|Select two (2) current references from nursing | | | |

|journals to support your nursing interventions. | | | |

|Both articles must be from nursing journals. One | | | |

|article must be research. Current articles are | | | |

|from within the last five years. | | | |

| | | | |

|Submit articles with case study | | | |

|Risk Factor |5 | | |

| | | | |

|Select one risk factor for your client and | | | |

|discuss the reason you choose this risk factor, | | | |

|i.e., significance to patient health. | | | |

| | | | |

|Pathophysiology | | | |

|See your clinical instructor if your client had | | | |

|no identifiable pathophysiology to determine an | | | |

|appropriate topic for this section. | | | |

|Pathophysiology |10 | | |

| | | | |

|Discuss the pathophysiological processes that | | | |

|occur or could occur with the risk factor you | | | |

|chose. | | | |

| | | | |

|Presenting Symptoms |5 | | |

| | | | |

|Identify presenting symptoms of your client. In | | | |

|addition, include typical signs and symptoms for | | | |

|this risk factor. | | | |

|Treatments: |5 | | |

| | | | |

|Discuss all standard medical treatments and | | | |

|nursing interventions, including patient | | | |

|education. | | | |

|Grammar/Syntax |10 | | |

|APA format including citations and bibliography | | | |

| | | | |

|Grading Rubric attached | | | |

| | | | |

|There is an example of a correct APA format paper| | | |

|on blackboard. If you have questions or would | | | |

|like assistance with editing or input, you may | | | |

|ask your clinical instructor for help or the | | | |

|clinical coordinator during class time (Linda | | | |

|Bennington, Phd,RN). | | | |

|Appendix |10 | | |

| | | | |

|Attach Case study client assessment | | | |

|Be sure it is accurate and thorough to include | | | |

|medications, side effects and purpose, and | | | |

|include significant lab values. | | | |

|Total Points: |100 | | |

Final Comments:

Appendix: Clinical Case Study Assessment

|Prenatal Course | | |

|Age |19 | |

|Ethnic Background |African American | |

|Educational Level |High school; currently taking classes at | |

| |Tidewater Community College | |

|GTPAL |G1T0P0A0L1 | |

|Past Pregnancies |0 | |

|Date of Delivery | | |

|Outcomes (SVD or C/S) | | |

|Risk factors | | |

|Current Status of children | | |

|LMP/EDC |LMP 1/21/12 | |

|Planned pregnancy? |EDC 10/27/12 | |

| |Not planned pregnancy | |

|Prenatal Care |Ghent Family Medicine | |

|(Where, when started, number of visits) |Began seeing doctor at approximately 4 | |

|Number of ultrasounds/significant findings |weeks (2/21/12); had 15-16 visits; 5 -6 | |

|Other testing |ultrasounds. Said baby was SGA initially | |

| |but weight “jumped” toward the end | |

|Nutrition/Vitamins (any changes with |OTC prenatal vitamins throughout | |

|pregnancy |pregnancy; stopped eating junk food; ate | |

| |healthier foods like “fruits, veggies, | |

| |milk, peanut butter” | |

|Gynecological History |Menarche onset age 12, usually for 4 to 5 | |

|(Menarche onset, duration and frequency, PAP |qmonth. Had not had a PAP smear before | |

|smears, problems, sexual partners, history of|2/21/12. Could not discuss sexual | |

|rape or abuse |partners/rape/abuse b/c significant other | |

| |present. Dx with Chlamydia 2 to 3 yrs. | |

| |Prior to pregnancy. Not currently a | |

| |problem. | |

|Medical or Surgical History |Received stitches on R flank from MVA at | |

|Any traumas? |age 9 | |

|Normal childhood diseases? | | |

|Psychological History |Hx of depression; diagnosed at age 13; | |

|Postpartum Depression? |took Prozac but not currently taking due | |

|Evidence of Bonding? |to pregnancy; reports “crying a lot” | |

| |during pregnancy | |

|Social/Cultural Factors |Unemployed student with no medical | |

|Employment/insurance/living quarters |insurance. Seeking assistance from | |

|Religious or spiritual beliefs |Medicaid. Parents financially supportive. | |

|Support System |Baptist. Lives with mother and boyfriend.| |

|Marital Status |Occasionally sees father and two brothers.| |

|Community Resources | | |

|Risk Factors or complications with this |Concern for IUGR; mom former smoker | |

|pregnancy | | |

|Intrapartal Course | | |

|Initial Assessment |VS 0700 T 98.4, P 56, BP |135/54, RR 18 |

|Vital signs |VS 1100 T 98.6, P 60, BP |124/74, RR 16 |

|SVE/SROM/Bleeding/Problems |Elective Induction of labor, failure to | |

| |progress led to cesarean section | |

|Fetal Monitoring |External FHR monitoring | |

|External or Internal or Both |HR 140 (baseline); variability (6-25 | |

|FHR Baseline |bpm), accels present, no decels | |

|Reactive/Nonreactive | | |

|Accels | | |

|Early/Late/Variable Decels? | | |

|Neonatal Course | | |

|Delivery Summary |40w3d Vaginal delivery with induction but | |

|Gestational age at delivery |failed to progress at 7 cm; C/S performed | |

|SVD or C/S | | |

|Forceps or Vacuum | | |

|Sex, Length/Weight |Male, 19.3in, | |

|Apgar score |7lb 1oz | |

|Resuscitation |Apgar 8/9 | |

|Risk Factors |Initial concern for IUGR, but resolved in | |

| |later pregnancy; mom former smoker | |

|Laboratory Findings |Pregnancy |Postpartum |

|Blood type |O positive |O positive |

|Rubella titer |Immune |Immune |

|VDRL/RPR (Syphilis) |neg |neg |

|HBsAg (Hep B) |neg |neg |

|GBS (Group B Strep) |neg |neg |

|HIV |neg |neg |

|Chlamydia |neg |neg |

|GC (Gonorrhea) |neg |neg |

|Glucose |92 |n/a |

|BUN |12 |n/a |

|Uric Acid |4.2 |n/a |

|WBC |13.0 |n/a |

|RBC |4.1 |n/a |

|Hct |35.9 |29.3 |

|Hgb |12.0 |9.9 |

|Urinalysis |Neg. |Neg. |

|Medications/Dosage/Route |Purpose |Side Effects/Contraindications/ |

| | |Nursing Implications |

| | | |

| | |Include your reference |

|Docusate Sodium (Colace) capsule 100 mg bid |Stool softener |Side effects: Mild GI cramping, throat irritation |

|oral | |Contraindications: nausea, vomiting, GI obstruction, |

| | |concomitant use of mineral oil |

| | |Implications: encourage fluids, assess for bowel |

| | |sounds |

| | |Implic.: Assess pain. Monitor respiratory depression.|

| | |Assess BP, pulse. Inc fluids, use stool softener. |

| | |Monitor voids |

|Lactated ringers (LR) infusion Continuous PRN|Fluid replacement |Monitor electrolytes; Assess I &O, lung sounds, |

|IV 125 mL/hr Dispensed volume:1,000 mL | |edema; IV site for extravascation; Monitor for signs |

| | |of fluid overload: edema, crackles in lungs, vital |

| | |signs. |

|Misoprostol (cytotec) tab 400 mcg prn rectal |Postpartum excessive bleeding |Contraindications: Pregnancy |

|rectal | |Side effects: Abdominal pain, diarrhea |

| | |Implications: Obtain CBC with differential before and|

| | |during therapy. Use antiemetic’s before and during |

| | |therapy |

|Oxycodone-acetaminophen (Percocet) 325 mg |pain |Contraindications: Not intended as an “as needed” |

|tablet q4h PRN oral | |analgesic or for immediate post-op pain control |

| | |Side effects: Dizziness, n/v, hypotension, |

| | |constipation |

| | |Implications: Assess pain, v/s, including |

| | |respirations. Notify physician and hold medication if|

| | |RR is less than 12. Assess for bowel movements. |

|Oxytocin (pitocin) 150 ml/hr IV continuous |Induces contractions (does not act on the |Side effects: tachycardia, hypotension, N/V |

|PRN |cervix) |Contraindications: fetal distress, uterine activity |

| | |that fails to progress |

| | |Implications: Monitor vitals q15 min, notify |

| | |physician if contractions last longer than one minute|

|Duramorph/Astromorph- Epidural, 1- 6 mg |Morphine given into epidural catheter, for|Side effects: sedations, decreased BP, flushing, |

|bolus, infusion rate 0.1-2 mg/hr |pain relief |orthostatic hypotension |

| | |Contraindications: acute or severe asthma, GI |

| | |obstruction |

| | |Implications: May prolong labor if given before 4-5cm|

| | |of cervical dilation. |

| | | |

|Reference: Lilley, L., Rainforth Collins, S., Harrington, S., and Snyder, J. (2011). Pharmacology and the Nursing Process, (6th ed.). St. |

|Louis: Elsevier |

| |

N331

Postpartum Assessment

|Physical Assessment |Variations and possible causes |Findings |

|Normal Findings |Prenatal Care beginning @4 wks |Admitted: _10/29/12___ |

|GTPAL G1T0P0A0L1 |Marital Status single |From: _Ghent Family Medicine__ |

|LMP 1/21/12 EDC 10/27/12 |Religious Pref_Baptist |Complications of this Pregnancy: |

|GA 40w 3d |Occupation_student |IUGR early in pregnancy but resolved, mother former smoker |

| |Ethnicity/Race_African American | |

|Vital Signs | | |

| | |0700 1100 |

|Blood Pressure—should remain consistent with |High BP (preeclampsia, essential hypertension, |135/54 124/74 |

|baseline during pregnancy. |renal disease, anxiety). Drop in BP (may be | |

| |normal; uterine hemorrhage). | |

|Pulses—(50-90bpm)—Maybe bradycardia of |Tachycardia (difficult labor and birth, |56 60 |

|50-70bpm. |hemorrhage). | |

|Temperature—(36.6-38C or 98-100.4F). |After first 24 hours temperature of 38C (100.4F) |98.4 98.6 |

| |or above suggests infection. | |

|Breasts | | |

|General Appearance—Smooth, even pigmentation,|Reddened area (mastitis). |Symmetrical, even pigmentation |

|changes of pregnancy still apparent; one may | | |

|appear larger. | | |

|Palpation—Depending on postpartal day, may be|Palpable mass (caked breast, mastitis). |Denies tenderness on palpation, filling |

|soft, filling, full, or engorged. |Engorgement (venous stasis). Tenderness, heat, | |

| |edema (engorgement, caked breast, mastitis). | |

|Nipples—Supple, pigmented, intact; become |Fissures, cracks, soreness (problems with |No fissures, cracks, soreness; states problems with having enough |

|erect when stimulated. |breastfeeding), not erectile with stimulation |milk |

| |(inverted nipples). | |

|Abdomen | | |

|Musculature—Abdomen may be soft, have a |Separation in musculature (diastasis recti |Soft, difficult to palpate. Incision dry, clean, and intact. |

|“doughy” texture; rectus muscle intact. |abdominis). | |

|Fundus—Firm, midline; following expected |Boggy (full bladder, uterine bleeding). |Soft, deviates left of umbilicus |

|process of involution | | |

|May be tender when palpated |Constant tenderness (infection) |Tender on palpation |

|Lochia | | |

|Scant to moderate amount, earthy odor; no |Large amount, clots (hemorrhage). Foul-smelling |Moderate amount serasanguinous; slight odor |

|clots. |lochia (infection). | |

|Normal progression: First 1-3 days: rubra. |Failure to progress normally or return to rubra |serosa |

|Following rubra: Days 3-10 serosa (alba |from serosa (subinvolution). | |

|seldom seen in hospital). | | |

|Perineum | | |

|Slight edema and bruising in intact perineum.|Marked fullness, bruising, pain (vulvar |Did not inspect perineum due to soreness from C-section. Refused |

| |hematoma). |exam. |

|Episiotomy—No redness, edema, ecchymosis, or |Redness, edema, ecchymosis, discharge, or gaping |No episiotomy |

|discharge; edges well approximated. |stitches (infection). | |

|Hemorrhoids—None present; if present, should |Full, tender, inflamed hemorrhoids. |Denies hemorrhoids |

|be small and nontender. | | |

|Costovertebral Angle (CVA) Tenderness | | |

|None |Present (kidney infection). |none |

|Lower Extremities | | |

|No pain with palpation; negative Homan’s sign|Positive findings (thrombophlebitis). |No pain on palpation, negative bilaterally for Homan’s sign. No |

|(if used in your facility, often not | |edema. |

|reliable). | | |

|Elimination | | |

|Urinary output—voiding in sufficient |Inability to void (urinary retention). Symptoms |Voided 200 mL two hours after foley d/c; dark peach urine |

|quantities at least every 4-6 hours; bladder |of urgency, frequency, dysuria (UTI). | |

|not palpable. | | |

|Bowel elimination—should have normal bowel |Inability to pass feces (constipation due to fear|Bowel sounds x 4 quadrants, passing flatus, no bowel movement |

|movement by second or third day after birth. |of pain from episiotomy, hemorrhoids, perineal | |

| |trauma). | |

|Cultural Assessment | | |

|Determine customs and practices regarding | |Patient denied specific cultural needs. Company was present |

|postpartum care. (Fluids, foods, temperature,| |throughout interview. |

|alone, company) | | |

|Psychosocial Assessment | | |

|Psychological Adaptation | | |

|During first 24 hours—Passive; preoccupied |Very quiet and passive; sleeps frequently |Preoccupied with own needs; talks little about baby but sounds |

|with own needs; may talk about her labor and |(fatigue from long labor, feelings of |excited when baby is mentioned; jovial |

|birth experience; may be talkative, elated or|disappointment about some aspect of the | |

|very quiet. |experience; may be following cultural | |

| |expectation). | |

|By 12 hours—Beginning to assume |Excessive weepiness, mood swings, pronounced |Somewhat overwhelmed; sent baby back to nursery so she could rest. |

|responsibility; some women eager to learn; |irritability (postpartum blues, feelings of |Changed diaper for the first time. |

|easily feels overwhelmed. |inadequacy; culturally proscribed behavior). | |

|Attachment | | |

|En face position; hold baby close; cuddles |Continued expressions of disappointment in sex, |Expresses some attachment but seems awkward and hesitant when |

|and soothes; calls by name; identifies |appearance of infant; refusal to care for infant;|holding baby and providing care |

|characteristics of family members in infant; |derogatory comments; lack of bonding behaviors | |

|may be awkward in providing care |(difficulty in attachment, following expectations| |

| |of cultural/ethnic group). | |

|Initially may express disappointment over sex| | |

|or appearance of infant but with in 1-2 days | | |

|demonstrated attachment behaviors. | | |

|Client Education | | |

|Has basic understanding of self-care |Unable to demonstrate basic self-care and infant |Very hesitant about performing self-care but is eager to learn. |

|activities and infant care needs; can |care activities (knowledge deficit; postpartum |Changed baby’s diaper with success but shows frustration and |

|identify signs of complications that should |blues; following prescribed cultural behavior and|exhaustion with breastfeeding. Client’s mother will be assisting |

|be reported |will be cared for by grandmother or other family |her at home. |

| |member). | |

Honor Code

I pledge to support the Honor System of Old Dominion University. I will refrain from any form of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a member of the academic community it is my responsibility to turn in all suspected violators of the Honor Code. I will report to hearing if summoned.

Signature: Jamie Martin Date: 12/9/2012

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