Exam (elaborations) NUR 3330 Stephanie Gold Room 303 Med-Surg (ALL EVA

Exam (elaborations) NUR 3330 Stephanie Gold Room 303 Med-Surg (ALL EVA Stephanie Gold, 19-year-old Caucasian female, G1 T0 P0 A0 L0, 32 weeks gestation. Uncomplicated pregnancy except for anemia treated with PO iron. States 3 times in last week has called on-call obstetrician about fatigue, body aches, mild nausea during the evening. The client reports, “I don’t feel well, I haven’t vomited, but nausea makes me not want to eat too much. I am drinking ok, just want to eat bland foods.” Rest and acetaminophen were recommended. Client is first-year nursing student and states several students have had a “GI bug”. States during day felt better and went to school all but one day. No fever. She stated: “Can’t be absent from nursing school!” No contractions, leaking of fluid or vaginal bleeding. Came in this morning (Saturday) due to pain by right rib cage. States this is new today. Boyfriend accompanies client. You responded correctly to 5 out of 6 evaluations: Category Your response Explanation Educational Needs Increased acuity Status Assessment reports r/t change in condition Fall Risk Normal acuity Status Assessment reports r/t physiological shifts of pregnancy/center of gravity NUR 3330 Stephanie Gold Room 303 Med-Surg (ALL EVALUATIONS) Category Your response Explanation Health Change Increased acuity Status Assessment reports r/t malaise/nausea/pain during pregnancy Pain Level Increased acuity Status Assessment reports r/t right upper quadrant pain Psychological Needs Increased acuity Status Assessment reports r/t concern about her baby’s health/her health and absence from nursing school Sensorium Normal acuity Status Assessment reports no indication in report that there is a change in sensorium Physiological Description Your Response Explanation Deficient Fluid Volume True Status assessment reports no generalized edema from fluid shift from intravascular to extravascular at this assessment/nausea not significant enough to cause deficit. Imbalanced Nutrition False Status assessment reports assessments do not show nutrition has been substantially impacted by slight nausea. Injury, risk for fetal True Status assessment reports r/t risk for uteroplacental insufficiency secondary to vasospasm if abdominal pain and malaise/elevated BP indicate preeclampsia/HELLP syndrome. Injury, risk for maternal True Status assessment reports r/t hypertension and vasospasm and potential decreased renal perfusion. Nausea True Status assessment reports experiencing slight nausea off and on this week. Safety Description Your Response Explanation Fall Risk True Status assessment reports r/t shifting center of gravity at 32 weeks gestation and in the third trimester. Injury, risk for maternal True Status assessment reports r/t risk for worsening preeclampsia to eclampsia and seizures. Love and Belonging Description Your Response Explanation Anxiety True Status assessment reports r/t unknown impact of current complication on mother and fetus. Disabled Family Coping True Status assessment reports no evidence of inappropriate family coping. Boyfriend accompanies. Risk for r/t High Risk Pregnancy and Financial Concerns. Health Maintenance; Ineffective False Status assessment reports r/t deficient knowledge about high risk pregnancy. Scenario 1 The nurse completes an initial assessment. T 37.4 C, 99.3 F; Heart rate 90, regular; RR 20, regular; BP 142/90 mmHg; FHR 145, moderate variability, 2 accelerations to 160 in 20 minutes, no decelerations. No contractions on electronic fetal monitoring or by palpation. Abdomen soft but tender in right upper quadrant. Urine negative for protein on dipstick. No vaginal bleeding or leaking of fluid. No pedal edema. DTR +3 bilaterally. Repeat blood pressure noted to be 144/90 mmHg. The HCP is notified of the assessment and orders are received. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: You correctly ordered 5 out of 5 actions: Your order Correct order Step Explanation 1 1 Explain all plan of care to client and significant other. Explanation of plan of care helps put client and significant other at ease, decrease anxiety. The must be done first. 2 2 Bedrest/side-lying position. Left lateral recumbent position decreases pressure on vena cava, therefore increasing venous return and placental and renal perfusion. This ensures that the fetus is also well perfused and is a priority. 3 3 CBC, Chemistry Panel, LFT, 24-hour urine for protein and creatinine. Contact the lab to come and draw these labs. The results of the lab will take several minutes and will drive the plan of care for the client. 4 4 Continuous EFM. Client and healthcare team are concerned about fetus. Hearing fetal heart will decrease client’s anxiety prior to taking her VS. Verifies fetal wellbeing. EFM has been in place but ultrasound and tocotransducer may need to be adjusted after turning client onto her left side. 5 5 Hourly VS and DTR. Client’s BP was elevated and DTR were brisker than average. By the time other actions have Your order Correct order Step Explanation been taken, it will be close to time for the hourly assessments. Scenario 2 The nurse is admitting this client to the high-risk antepartum unit to monitor blood pressure and other assessments and to await lab findings. The nurse adds independent nursing actions to the plan of care. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: You correctly ordered 6 out of 6 actions: Your order Correct order Step Explanation 1 1 Elevate and pad side rails. Her DTRs are +3 so she is slightly hyper-reflexic and at risk for seizures. Padding side rails protects her from injury if she has a seizure. Safety first! 2 2 Ensure oxygen and suction are working properly. Airway and breathing precautions next. If client has a seizure, suction may be needed to clear airway. (She is already positioned on her side) During a seizure, client would have a period of apnea which would cause fetal hypoxemia. Applying oxygen to mother would increase oxygen available to fetus. Ensure both are working before needed in an emergency situation. 3 3 Emergency medications brought to the client’s room or verified as accessible. Magnesium sulfate, calcium gluconate, hydralazine, nifedipine are often in an emergency “toolbox” and brought to client’s room for immediate access if needed; anticipating one or more of these meds will be ordered if complications such as preeclampsia, eclampsia, or HELLP syndrome occur. This is done as per agency policy. 4 4 Bring extra pillows to enhance comfort in side-lying position and place between knees, behind back, and under abdomen. Enhancing comfort in the side-lying position will enable the client to maintain this position. Side-lying decreases pressure on the vena cava, increases venous return, placental and renal perfusion. Comfort measures are completed after emergency interventions. 5 5 Bring bedpan, graduated cylinder, 24- hour urine container, ice into the room. Healthcare provider ordered 24-hour urine so bringing supplies for this collection would be necessary. The nurse may include intake and output in the care plan independently. At least 30 mL of hourly urine output demonstrates minimal kidney function. Left lateral position enhances renal perfusion, thereby decreasing angiotensin levels, and promotes diuresis. 24 hour I&O documents positive or negative fluid balance. 6 6 Educate client and significant others about 24-hour urine collection, I&O and documenting oral intake. Educating and involving the client and significant others in the plan of care helps to decrease anxiety and empower them as important members of the health care team. Education occurs after other physiological needs are met. Your order Correct order Step Explanation Your order Correct order Step Explanation 2 2 Initiate peripheral IV with Lactated ringer’s infusing at 50 mL/hour. Magnesium sulfate is a high alert medication and should be administered as a secondary medication. A primary line is started with an isotonic solution, like Lactated Ringer’s. To reduce the risk of pulmonary edema, total intake should be less than 125 mL/hour. 3 3 Piggyback magnesium sulfate solution into primary IV, set infusion at 400 mL/hour for 15 minutes; volume to be infused 100 mL. An initial loading dose of 4 to 6 grams over 15-30 minutes helps raise magnesium blood levels to a therapeutic level of 4-7 mEq/L and prevent eclamptic seizures. 4 4 IM betamethasone 12 mg. While the loading dose of magnesium sulfate is infusing, administer the IM steroid injection to enhance fetal lung maturity for gestations less than 34 weeks. Neonatal benefit is maximized when the interval between the first injection and birth is longer than 48 hours, but benefits begin within 4 hours of administration. The benefit of one injection is unclear but is often given without harm. 5 5 Change infusion rate to 50 mL/hour Magnesium sulfate 20 grams/500 mL for the remainder of 400 mL. Followed by an hourly infusion of 2grams/hour. An infusion pump is used for accuracy and less risk of magnesium toxicity. Scenario 4 Two hours into the magnesium infusion, the client states she has a “really bad” headache and she “can’t see very well”. Her eyes become fixed and her facial muscles begin to twitch. The nurse is monitoring fetal heart tones. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: Not all actions will be used