Student Case study placental abruption ALL ANSWERS 100% CORRECT FALL-2021 GUARANTEED GRADE A+

THINK Like a Nurse by Recognizing RELEVANCE and PRIORITIES Michelle Moore 38yr old Four Principles of Clinical Reasoning: 1. Identify and interpret RELEVANT clinical data. 2. TREND relevant clinical data to determine current status (stable vs. unstable). 3. Grasp the “essence” of the current clinical situation. 4. Determine nursing PRIORITY and plan of care. History of Present Problem: Michelle Moore is a 38-year-old who is 29 weeks pregnant. She began prenatal care at 18 weeks gestation because she was waiting to become insured. She is currently being seen in the Labor and Delivery Unit of the hospital following a call to her health care provider in which she stated she has had constant uterine pain she rated at 6/10 accompanied by vaginal bleeding and decreased fetal movement the past several hours. Past Medical History Home Meds: • Gravida 4, Para 1 with a partial abruption at 38 weeks • Menses began at age 12, are usually 29 days apart, lasting for 4-5 days, with moderate-to-light flow. • Successfully breast fed her first child for 11 months. • Vaccinations are up to date. • Michelle is biracial: African American and Asian, and she was tested for sickle cell trait. Lab results reveal Michelle is a carrier of the trait. It is unknown if the father of the baby is also a carrier. 1. Prenatal vitamin 1 tab PO daily 2. Acetaminophen 650 mg PO PRN every 4 hours for infrequent, mild headaches What data from the PRESENT PROBLEM are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT Data from Present Problem: Clinical Significance: • Advanced maternal age • 29 weeks gestation • Delayed prenatal care • Experiencing uterine pain and vaginal bleeding with decreased fetal movement • Previous abruptions • G4P1 • Sickle cell trait carrier • Risk factor for placental abruption • Baby is not term yet, need to be aware of possible resources to resuscitate baby when it is born • Delayed care to fetus and decreased amount of monitoring  risk for unnoticed complications • Signs commonly found in placental abruption fetus could not be getting what it needs such as O2 and nutrients • Very big risk factor for experiencing placental abruption again • History of complicated pregnancies • If dad is also a carrier, baby could be affected for hemodynamic issues Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 98.5 F/ 36.9 C (oral) Provoking/Palliative: Constant, nothing makes it worse or better P: 102 (regular) Quality: “knife-like” R: 20 (regular) Region/Radiation: abdominal BP: 102/64 MAP: 77 Severity: 8/10 O2 sat: 96% room air Timing: constant What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: • Decreased BP, slightly increased pulse • BP could be decompensating for blood loss, elevated pulse could be because of discomfort she is experiencing but blood loss would present with lowered BP and elevated pulse • Knife like abdominal pain that is constant, pain has increased from her history • Sign of placental abruption “knife like” not what normal contractions would feel like, nothing makes it worse/better, no meds work and her pain has increased from 6/10 to 8/10 Current Assessment: GENERAL APPEARANCE: 5’ 4” (162.5 cm) tall and weighs 165 pounds (75 kg), including 25 pounds (11.4 kg) she gained during this pregnancy. Appears uncomfortable, groaning and holding abdomen RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort CARDIAC: Pale, cool/dry, no edema, heart sounds regular with no abnormal beats, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert and oriented to person, place, time, and situation (x4) BUBBLE-HE BREAST: Soft, non-tender with evidence of colostrum UTERUS: Firm, rigid, tender upon palpation BLADDER: Voiding regularly BOWELS: Abdomen rigid, tender; bowel sounds audible per auscultation in all four quadrants Vaginal Bleeding: Dark red (port wine) vaginal bleeding on pad, about 50% of pad is blood-stained in 30 minutes HOMANS: Negative EPISIOTOMY: n/a Electronic Fetal Monitoring: Fetal heart rate 120, minimum variability around the baseline, occasional variable decelerations, no accelerations noted. Contractions are rare: 1 every 20 minutes, uterus is board-like upon palpation What assessment data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: • Firm and tender uterus • Skin pale and dry • Dark red blood • Weight gain • Edema • Category 2 tracing • Could indicate piling of blood within the placenta • Consistent with signs of shock • Classic placental abruption sign older blood piling up in the uterus/vagina and just now being released from the vagina • Higher than recommended • Weight gain is not from retained fluid • Not fully showing cord compression, not reassuring, and something is definitely abnormal Lab Results: Complete Blood Count (CBC:) (Pregnancy Values) Current: High/Low/WNL? Previous: WBC (5,000 – 15,000 mm 3) 15.1 14.8 Hgb (11.5-14 g/dL) 9.5 11.2 Platelets (150-350 x103/µl) 101 122 What lab results are RELEVANT and must be recognized as clinically significant by the nurse?