Case Study

Jessica Thompson And Erika Tallman

Demographics

   

T.L.

29 years old G6P5AB1L4 LMP 8/31/10       baby girl 6 lbs 7oz Born 6/1/11 at 1709 39weeks and 1 day gestation. EDD 6/7/11 Bottle feeding (Maternal preference)

OB history

      Pregnancy #1:was an ectopic pregnancy.

Pregnancy #2: resulted in the preterm labor at 36 weeks.

Pregnancy #3: resulted in another preterm labor at 35 weeks.

Pregnancy #4: resulted in fetal demise at 32 weeks gestation related to cervical funneling.

Pregnancy #5: resulted in a full term baby boy.

Pregnancy #6: resulted in a full term baby girl.

 IUFD

Fatal Pregnancies

Occurred at 32 weeks gestation when cervical funneling (cone shaped indentation in the cervical os took place) which she birthed .  Ectopic Occurred when the ovum implanted into a site other than the lining of the uterus.

Incompetent cervix

   Painless dilation of the cervix without contractions because of a structural or functional defect of the cervix. Related risk factors include: multiple gestations and previous preterm births Education would include the warning signs of preterm labor: lower back pain, pelvic pressure, and changes in vaginal discharge; and the benefits of a cerclage placement.

Cerclage

   Surgical procedure in which the cervix is sewn shut primarily in the third month pregnancy (T.L. had this done at 13 weeks, laproscopically), to keep the cervix from prematurely dilating. Successful in 80-95% of cases.

Generally removed in the 37 th week of pregnancy, but can be removed earlier if ROM or true labor contractions occur.

Cervical Cerclage, 2006

video

http://www.youtube.com/watch ?v=630Ax6N6yp0&feature=autopl ay&list=PLB5A0A679455613C2&in dex=1&playnext=2 (elitelaproscopic, 2010)

Ultrasound Criteria for the Diagnosis of Incompetent Cervix Cervical Length Normal Pregnancy >3 cm Cervical incompetence <3 cm Cervical Width Cervical Canal Width <2 cm in second trimester. <8 mm >2 cm in second trimester. >8 mm Cervical funneling None or < 25% 25-50% or > 50% None Bulging of Membranes into cervical canal Present ± fetal parts

J. Ludmir

PP Bilateral tubal ligation “having your tubes tied”

   Permanent, irreversible form of birth control that is over 99% effective. Procedure includes making an incision just above the navel and using laparoscopic tools to snip the fallopian tubes and cauterize them, pain is relieved through the use of anesthesia. Can be done in an outpatient setting.

Test

Lab work

Blood work

Type &Rh

Normal PT result

Maternal :O+ Baby: B+ Hemoglobin & hematocrit VDRL/ RPR 11mg/dL & 33% in pregnancy 11.5mg/dL & 34% Negative Rubella GC-C

Other

GBS negative Immune Negative positive

analysis Risk for ABO incompatibility, may cause newborn jaundice R/T hemolysis; hyperbilirumia. Rh is not an issue.

No issues No risk to fetus No risk to fetus No risk to fetus Treatment given: penicillin X 2

Pregnancy Related tests

Test

Pap smear 1 hr Glucose tolerance Biophysical Profile NST

Normal

<130mg/dL 8-10

PT Result

Normal 129mg/dL 9 2 accelerations of at least 15 bpm for 15 seconds within 20 mins Reactive

Analysis

No STIs or cancer No GDM Fetal wellbeing Fetal wellbeing

Labor and Delivery

  T.L’s labor was induced when her Cerclage was removed on 5/31/11 and amniotomy at 1915, with an epidural, LR with pitocin, and a foley bulb, her labor took 22 hrs, with a 9 minute 2 nd stage and a 3 minute 3 rd loss and a 2 nd stage, with 250mL blood degree laceration. Because T.L. was gbs+, she was also taking penicillin via a IV piggyback.

Labor and Delivery contd.

 FHR remained in the 130s bpm with moderate variability, monitored consistently with an external transducer.

 The baby girl scored a 9 out of 10 on the APGAR scale at 1 and 5 minutes of age.

PP assessment

Vitals  0900 : BP 124/76, HR 70, R 14, T 36.7

 Pain 0/10  1400 : BP 122/74, HR 66, R 14, T 36.5

 Pain 4/10 medicated with vicodin and motrin  BUBBLE-HEB was within normal limits

Newborn assessment

Vitals  0800 : HR 140, R 45, T 36.5

 Pain 0/10  1500 : HR 150, R 45, T 36.5

 Pain 0/10      Reflexes present Skin and mucosa within normal limits fontanels soft and level Symmetrical movements Voiding adequatelt

Newborn Feedings

 T.L.’s choice to not breastfeed, the baby girl now gets her nutrition through Similac advanced formula every 3-4 hours.

 1.

Feedings

0530- 22cc 2.

3.

4.

5.

0900- 20cc 1130-5cc 1300-5cc 1530- 5cc

PP medications

     Vicodin: Opiod analgesic, generalized CNS depression for moderate pain.

1 tab (5mg) q4hr PO : not to exceed 4000mg/day.

Prenatal vitamin: with iron supplement. 1 tab/day Motrin: nonopiod analgesic/nonsteroidal anti inflammatory/ antipyretic: inhibits prostaglandin synthesis.

Prn: 600 mg q6hr PO Americaine ointment: anesthetic, local pain relief Prn applied topically Tucks(witch hazel) pads: analgesic, local pain relief R/T hemorrhoids. Prn applied topically

education

Nursing Diagnosis #1

Risk for infection

AEB… inadequate primary defenses, invasive procedures and environmental exposure.

• Normal labor trauma • Tubal procedure • • Not as active Hospital environment Goal: Be free of purulent drainage or secretions, and other signs of infections throughout the healing process.

Evaluation: At this time the patient was free of infection and expressed understanding of education.

Intervention 1 Monitor and educate on the following for signs of infection: ■Redness, swelling, increased pain, or purulent drainage at incisions, injured sites, exit sites of tubes, drains, or catheters Any suspicious drainage should be cultured;

antibiotic therapy is determined by pathogens identified at culture.

■Elevated temperature Fever of up to 38° C (100.4° F) for 48 hours after surgery is related to surgical stress; after 48 hours, fever above 37.7° C

(99.8° F) suggests infection; fever spikes that occur and subside are indicative of wound infection; very high fever accompanied by sweating and chills may indicate septicemia.

■Color of respiratory secretions

Yellow or yellow-green sputum is indicative of respiratory infection.

■Appearance of urine Cloudy, foul smelling urine with visible sediment is

indicative of urinary tract or bladder infection.

Check and chart vitals every shift for comparison.

Give written information about signs of infection Physician should be notified of any signs or symptoms of infection

Teach patient or caregiver to wash hands often, especially after toileting, before meals, and before and after administering self-care.

Patients and caregivers can spread infection from one part of the body to another, as well as pick up surface pathogens; hand washing reduces these risks.

Note patient compliance of proper perineal cleanser and hygiene Intervention 2 Wash hands before and after client care Note patient understanding of education given

psychological

Nursing Diagnosis #2

Risk for disturbed body image

• AEB… situation, focus on past appearance, change in social involvement • Multiple pregnancies 40 lbs weight gain, wishes to lose all • Newborn to care for Goal: improve and maintain self-esteem through the first post-partal year illustrated verbally.

Evaluation: At this time the patient is unsatisfied with current body weight and BMI illustrated by verbal negativity.

Note patient’s behavior regarding actual or perceived changed body part or function. There is a

broad range of behaviors associated with body image disturbance, ranging from totally ignoring the altered structure or function to preoccupation with it.

Give information about realistic weight loss goals Intervention 1 Allow patient to initiate conversation about subject of her body Promote patient to communicate concerns with family and healthcare provider

Assist patient in incorporating actual changes into ADLs, social life, interpersonal relationships, and occupational activities.

Opportunities for positive feedback and success in social situations may hasten adaptation

Discuss healthy nutritional and physical activity options Intervention 2 Be positive in conversations Give information pertaining to breastfeeding and the extra calories burned along with the importance for the newborn

nutrition

Nursing Diagnosis #3

Newborn: imbalanced nutrition: less than body requirements AEB… lack of interest in food • Decreased intake Goal: maintain and increase weight, be free of signs of malnutrition daily and throughout early childhood Evaluation: At this time the patient is not having adequate intake

Intervention 1 Monitor laboratory values that indicate nutritional well being/deterioration: Serum albumin: This indicates

degree of protein depletion

(3.8 to 4.5 g/dl is normal).

Transferrin: This is important

for iron transfer and typically decreases as serum protein decreases.

RBC and WBC counts: These

are usually decreased in malnutrition, indicating anemia and decreased resistance to infection.

Serum electrolyte values:

Potassium is typically increased and sodium is typically decreased in malnutrition

Draw labs once daily for evaluation Document any values off baseline/norm and notify physician Evaluate any supplemental options if lab values are abnormal

Intervention 2 Suggest ways to assist patient with meals as needed. This educates

and encourages adequate feedings.

Ensure a pleasant environment, to

improve comfort levels both maternally and for

the newborn. facilitate proper positioning;

nipple placement and a proper latch

facilitates feeding and provide good oral hygiene to reduce risk

of aspiration

Encourage frequent and possible smaller meals Make sure formula is at a comfortable temperature, and nipple is appropriate Monitor weight gain and I&O

physiological

Nursing Diagnosis #4

Disturbed sleep pattern AEB… situation and environmental • changes Previously prescribed sleep aide Hospitalization • 4 • th Newborn at home child living in household Goal: Verbalize increased sense of well being and adequately rested within discharge and by the first follow-up doctors appointment Evaluation: At this time the patient is not getting adequate rest, illustrated verbally.

Identify factors that may facilitate or interfere with normal patterns. Knowledge

of its role in health/wellness and the wide variation among individuals may allay anxiety, thereby promoting rest and sleep.

Allow mother alone time to rest when she chooses Intervention 1 Provide comfort measures that assist in relaxation Evaluate and educate on help from family and friends once at home

Instruct patient to follow as consistent a daily schedule for retiring and arising as possible. This promotes

regulation of the circadian rhythm, and reduces the energy required for adaptation to changes.

Monitor current sleep pattern and consult with physician for pharmacological measures if needed. Intervention 2 Discuss sleep patterns effective with previous pregnancies Provide information on the importance of sleep and various tricks to allow for adequate sleep.

References

 (2006). In Cervical Cerclage. Retrieved Jun. 7, 2011, from http://www.americanpregnancy.org/pregna ncycomplications/cervicalcerclage.html

 Body Image Disturbance; Weight training may be effective for body- imaged-disturbed college women :[1]. (2004, November). Obesity, Fitness & Wellness Week,141. Retrieved June 13, 2011, from ProQuest Nursing & Allied Health Source. (Document ID: 738930181).  Doenges, M, & M. Moorhouse, & A. Murr. (2010). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span. Philidelphia, PA: F.A. Davis.  elitelaproscopic,. (2010, Mar. 3 ). In Laproscopic Cervioc-Isthmic Cerclage. Retrieved Jun. 7, 2011, from http://www.youtube.com/watch?v=630Ax6N 6yp0&feature=autoplay&list=PLB5A0A679455 613C2&index=1&playnext=2  Fogelson, N.. (2010, Feb. 27 ). In Cerclage How-To . Retrieved Jun. 7, 2011, from http://academicobgyn.com/2010/02/27/ac ademic-obgyn-cases-abdominal-cerclage how-to  Gulanik, Myers, Klopp, Galanes,. (2009). In EHS: Nursing Care Plans: Diagnosis and Intervention. Retrieved Jun. 8, 2011, from http://www1.us.elsevierhealth.com/MERLIN/Gula nick/Constructor  Harmat, L., Takács, J., & Bódizs, R.. (2008). Music improves sleep quality in students. Journal of Advanced Nursing, 62(3), 327. Retrieved June 13, 2011, from ProQuest Nursing & Allied Health Source. (Document ID: 1468397021).  Louey, M.. (2006). Formula Feeding: Fluid Evidence Summaries. Retrieved June 13, 2011, from Evidence-Based Resources from the Joanna Briggs Institute. (Document ID: 1445804761).  Ludmir, J. In Ultrasound Criteria for the Diagnosis of Incompetent Cervix. Retrieved Jun. 8, 2011, from http://www.fetalultrasound.com/online/text/33 039.htm

 Stulberg JJ, Delaney CP, Neuhauser DV, Aron DCm FU P, Koroukian SM. Adherence to Surgical Care Improvement Project Measures and the association with postoperative infections. JAMA. 2010; 303(24): 2479-2485.