Lee Arthur NSG VSIM: Olivia Jones
211
CONCEPT MAP WORKSHEET
DESCRIBE DISEASE PROCESS AFFECTING
PATIENT (INCLUDE PATHOPHYSIOLOGY OF
DISEASE PROCESS)
Preeclampsia is classified as generalized vasospasm. This is characterized by a high blood pressure as well as other signs of damage to other
organs (kidneys, liver). A woman can have normal blood pressure throughout her pregnancy and then after 20 weeks gestation begin to show
signs of preeclampsia. Mild preeclampsia is a blood pressure of >140/90mmHg, and severe preeclampsia is a blood pressure of
>160/110mmHg. If this is left untreated it can lead to complications for the patient and the baby. Usually the most effective treatment is to
delivery the baby. Preeclampsia can cause pulmonary edema, seizures, abnormal liver enzymes, oliguria, and thrombocytopenia.
Preeclampsia can devlop with or without symptoms. However, the most relevant one is the elevated blood pressure and the proteinuria.
The patient can also experience severe headaches, vision changes, upper epigastric pain, decreased urine output, nausea and vomiting,
decreased platelets, and SOB. Diagnosis is done by urine dip test to see if there is protein in the urine, blood test are done to check liver
fuction and blood counts. Fetal ultrasound needs to be performed to monitor the baby‟s growth as well as weight and the amount of
amniotic fluid there is. Lastly, there is a biophysical profile that is performed to check the baby‟s heart rate as it moves. As preeclampsia
increases in severity so does the risk of seizures, stroke, placental abruption so the most effective treatment is delivery.
**continued on page 8!
DIAGNOSTIC TESTS (REASON FOR PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS
TEST AND RESULTS)
Urine Test monitor for proteinuria • c/o epigastric pain
Patient complains of nausea
Blood Test such as Hepatic function • chest tightness
Patient complains of severe
(AST/ALT) to monitor for organ • first pregnancy headache
damage CBC monitor for platelets, • positive protein dip test
(+4) Blurred vision or vision
RBCs, MCH, MCHC
• increased weight 3lbs in 1 changes SOB
Ultrasound: monitor baby „s growth:
week Increased weight gain
weight,amniotic fluid
Nonstress test (biophysical profile): • +2 dependent edema Patient complains about right
• Facial puffiness upper gastric pain
assessment of fetus: monitor FHR upon
movement, breathing, muscle tone, • BP 146/92 @32 week Elevated Blood Pressure
gestation visit (>140 systolic)
amniotic fluid volume
• Bed rest Increased urine output
• African American Facial puffiness
Dependent Edema
ANTICIPATED NURSING INTERVENTIONS
Daily weights Provide emotional support
Assess vitals Q4H especially BP, Administer medications as prescribed
HRAuscultate lung sounds Initiate Seizure precautions
Monitor FHR via tocoductor Intitiate Fall Risk
Monitor lab values daily: proteinuria, CBC, AST, Maintain patient in side-lying position
ALT Obtain Ultrasound Side Rails up X2 and padded
Assess for dependent edema All emergency supplies at bedside (suction, O2,
Monitor SpO2 canister)
Monitor and limit visitors, light, sounds Maintain adequate hand hygiene
Apply nonrebreather Assess neurological status
Assess vision for any significant changes Monitor I&O
Assess pain level Assess DTR
Monitor progession of preeclampsia Provide patient education
NSG 211 VSim: Olivia Jones
, Lee Arthur NSG VSIM: Olivia Jones
211
vSim ISBAR ACTIVITY STUDENT
WORKSHEET
INTRODUCTION I‟m Rebekah Taylor, SN from L&D reporting about O.J.
Your name, position (RN), unit you
are working on
SITUATION O.J. is 23-year old African American female G1P0 at 36 weeks gestation.
At 30 week appointment patient had increased BP of 146/92, protein in
Patient‟s name, age, specific reason for visit urine present and developing mild preeclampsia. She was admitted to
L&D for further assessment and observation for diagnosis of severe
preeclampsia. Patient presents with elevated BP, SOB and nausea. At this
time does not want to take anything for her nausea.
BACKGROUND O.J. was admitted for severe preeclampsia on 10/20/2020. NKDA, Full
code. Current orders are as follows: NPO status until serum lab results are
Patient‟s primary diagnosis, date of back, bed rest with bathroom privileges, BP Q1H X 2 then Q4H; T, P, RR
admission, current orders for patient Q1H, assess breath sounds Q4H, FHR/UC monitoring, DTR Q1H, head to
toe assessment Q4H, continuous SpO2, ultrasound, indwelling foley
catheter, intitiate seizure precautions, place seizure pads on side rails,
decrease stiluli, non-rebreather mask for O2 saturation of <92%. LR
infusing via IV in left forearm at 125mL/hr continuous. Ultrasound
ordered. Vital signs at 2:04 were as follows: T 99F, P 114, R 22, BP
172/102, O2 91% RA and FHR 155. Provider notified via orders.
ASSESSMENT Patient complains of vision changes headache, epigastric pain. Does not
want anything for the pain. Crackles heard in lower lobes of lungs
Current pertinent assessment data using head to bilaterally. Dependent edema noted at 3+, DTRs performed and 4+
toe approach, pertinent diagnostics, vital bilaterally with signs of clonus. Labs show low platelet count, low RBCs,
MCH, MCHC and an elevated creatinine, BUN, ALT/AST. Urine showed
signs
protein in the urine 4+. Ultrasound performed showed no abnormalities.
Indwelling urinary catheter placed; tolerated well. IV access in left
antecubital established with Magnesium sulfate 6g infusing at 200mL/hr
per new physician orders. Vital signs were as follows:
17:52 T 99, P 104, R 22, BP 168/101, SpO2 98% at 10L/min via
nonrebreather FHR 150
24:52 T 99, P 104, R 22, BP 166/100, SpO2 98% at 10L/min via
nonrebreather FHR 150
Physician notified and is coming to see patient.
No outstanding results at this time. Patient is stable at this time.
RECOMMENDATION
I suggest continuation of monitoring VS, FHR, and pain levels. She
Any orders or recommendations you mayhave should be placed on seizure precautions; however, bed pads and decreased
for this patient stimuli have been established. Continue to monitor for preeclampsia and
eclampsia. I also reccommed that a fall risk bracelet be placed on patient
and fall precautions be initiated. Contractions and FHR should be
continuously monitored. BP measured every hour. If physician has not
come to see patient within 15 minutes call again and see what she
recommends for medications for pain and precautions.
NSG 211 VSim: Olivia Jones
211
CONCEPT MAP WORKSHEET
DESCRIBE DISEASE PROCESS AFFECTING
PATIENT (INCLUDE PATHOPHYSIOLOGY OF
DISEASE PROCESS)
Preeclampsia is classified as generalized vasospasm. This is characterized by a high blood pressure as well as other signs of damage to other
organs (kidneys, liver). A woman can have normal blood pressure throughout her pregnancy and then after 20 weeks gestation begin to show
signs of preeclampsia. Mild preeclampsia is a blood pressure of >140/90mmHg, and severe preeclampsia is a blood pressure of
>160/110mmHg. If this is left untreated it can lead to complications for the patient and the baby. Usually the most effective treatment is to
delivery the baby. Preeclampsia can cause pulmonary edema, seizures, abnormal liver enzymes, oliguria, and thrombocytopenia.
Preeclampsia can devlop with or without symptoms. However, the most relevant one is the elevated blood pressure and the proteinuria.
The patient can also experience severe headaches, vision changes, upper epigastric pain, decreased urine output, nausea and vomiting,
decreased platelets, and SOB. Diagnosis is done by urine dip test to see if there is protein in the urine, blood test are done to check liver
fuction and blood counts. Fetal ultrasound needs to be performed to monitor the baby‟s growth as well as weight and the amount of
amniotic fluid there is. Lastly, there is a biophysical profile that is performed to check the baby‟s heart rate as it moves. As preeclampsia
increases in severity so does the risk of seizures, stroke, placental abruption so the most effective treatment is delivery.
**continued on page 8!
DIAGNOSTIC TESTS (REASON FOR PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS
TEST AND RESULTS)
Urine Test monitor for proteinuria • c/o epigastric pain
Patient complains of nausea
Blood Test such as Hepatic function • chest tightness
Patient complains of severe
(AST/ALT) to monitor for organ • first pregnancy headache
damage CBC monitor for platelets, • positive protein dip test
(+4) Blurred vision or vision
RBCs, MCH, MCHC
• increased weight 3lbs in 1 changes SOB
Ultrasound: monitor baby „s growth:
week Increased weight gain
weight,amniotic fluid
Nonstress test (biophysical profile): • +2 dependent edema Patient complains about right
• Facial puffiness upper gastric pain
assessment of fetus: monitor FHR upon
movement, breathing, muscle tone, • BP 146/92 @32 week Elevated Blood Pressure
gestation visit (>140 systolic)
amniotic fluid volume
• Bed rest Increased urine output
• African American Facial puffiness
Dependent Edema
ANTICIPATED NURSING INTERVENTIONS
Daily weights Provide emotional support
Assess vitals Q4H especially BP, Administer medications as prescribed
HRAuscultate lung sounds Initiate Seizure precautions
Monitor FHR via tocoductor Intitiate Fall Risk
Monitor lab values daily: proteinuria, CBC, AST, Maintain patient in side-lying position
ALT Obtain Ultrasound Side Rails up X2 and padded
Assess for dependent edema All emergency supplies at bedside (suction, O2,
Monitor SpO2 canister)
Monitor and limit visitors, light, sounds Maintain adequate hand hygiene
Apply nonrebreather Assess neurological status
Assess vision for any significant changes Monitor I&O
Assess pain level Assess DTR
Monitor progession of preeclampsia Provide patient education
NSG 211 VSim: Olivia Jones
, Lee Arthur NSG VSIM: Olivia Jones
211
vSim ISBAR ACTIVITY STUDENT
WORKSHEET
INTRODUCTION I‟m Rebekah Taylor, SN from L&D reporting about O.J.
Your name, position (RN), unit you
are working on
SITUATION O.J. is 23-year old African American female G1P0 at 36 weeks gestation.
At 30 week appointment patient had increased BP of 146/92, protein in
Patient‟s name, age, specific reason for visit urine present and developing mild preeclampsia. She was admitted to
L&D for further assessment and observation for diagnosis of severe
preeclampsia. Patient presents with elevated BP, SOB and nausea. At this
time does not want to take anything for her nausea.
BACKGROUND O.J. was admitted for severe preeclampsia on 10/20/2020. NKDA, Full
code. Current orders are as follows: NPO status until serum lab results are
Patient‟s primary diagnosis, date of back, bed rest with bathroom privileges, BP Q1H X 2 then Q4H; T, P, RR
admission, current orders for patient Q1H, assess breath sounds Q4H, FHR/UC monitoring, DTR Q1H, head to
toe assessment Q4H, continuous SpO2, ultrasound, indwelling foley
catheter, intitiate seizure precautions, place seizure pads on side rails,
decrease stiluli, non-rebreather mask for O2 saturation of <92%. LR
infusing via IV in left forearm at 125mL/hr continuous. Ultrasound
ordered. Vital signs at 2:04 were as follows: T 99F, P 114, R 22, BP
172/102, O2 91% RA and FHR 155. Provider notified via orders.
ASSESSMENT Patient complains of vision changes headache, epigastric pain. Does not
want anything for the pain. Crackles heard in lower lobes of lungs
Current pertinent assessment data using head to bilaterally. Dependent edema noted at 3+, DTRs performed and 4+
toe approach, pertinent diagnostics, vital bilaterally with signs of clonus. Labs show low platelet count, low RBCs,
MCH, MCHC and an elevated creatinine, BUN, ALT/AST. Urine showed
signs
protein in the urine 4+. Ultrasound performed showed no abnormalities.
Indwelling urinary catheter placed; tolerated well. IV access in left
antecubital established with Magnesium sulfate 6g infusing at 200mL/hr
per new physician orders. Vital signs were as follows:
17:52 T 99, P 104, R 22, BP 168/101, SpO2 98% at 10L/min via
nonrebreather FHR 150
24:52 T 99, P 104, R 22, BP 166/100, SpO2 98% at 10L/min via
nonrebreather FHR 150
Physician notified and is coming to see patient.
No outstanding results at this time. Patient is stable at this time.
RECOMMENDATION
I suggest continuation of monitoring VS, FHR, and pain levels. She
Any orders or recommendations you mayhave should be placed on seizure precautions; however, bed pads and decreased
for this patient stimuli have been established. Continue to monitor for preeclampsia and
eclampsia. I also reccommed that a fall risk bracelet be placed on patient
and fall precautions be initiated. Contractions and FHR should be
continuously monitored. BP measured every hour. If physician has not
come to see patient within 15 minutes call again and see what she
recommends for medications for pain and precautions.
NSG 211 VSim: Olivia Jones
