Exam (elaborations) Antepartum Care UNFOLDING Reasoning ; Anne Jones Is A 17-year-old

Exam (elaborations) Antepartum Care UNFOLDING Reasoning ; Anne Jones Is A 17-year-old Safe and Effective Care Environment • Management of Care 17-23% • Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12% Psychosocial Integrity 6-12% Physiological Integrity • Basic Care and Comfort 6-12% • Pharmacological and Parenteral Therapies 12-18% • Reduction of Risk Potential 9-15% • Physiological Adaptation 11-17% Anne Jones, 17 years old Antepartum Care UNFOLDING Reasoning ; Anne Jones is a 17-year-old History of Present Problem: Anne Jones is a 17-year-old Caucasian teenager who thinks she may be pregnant because she has missed two periods. Her last menstrual period, she thinks, was about one month ago. She states she had a little bit of spotting last week but didn’t have a “full period”. She complains of her breasts being tender, swollen, frequent urination, and nausea in the morning. This is her first office visit and she is not sure why she feels so crummy but suspects she might be pregnant. Her urine pregnancy test is positive. Her primary care provider orders a prenatal lab panel and a urinalysis. Personal/Social History: Anne is a senior in high school who stands on her feet while working at McDonalds after school. She drinks six colas daily, denies alcohol use, and does not smoke. She takes no medications except for occasional acetaminophen for headaches and ibuprofen for menstrual cramps. Anne is 5’4” (160 cm) and weighs about 105 lbs. (47.7 kg) according to Anne. A 24-hour recall nutrition history reveals a typical day’s diet: breakfast- pop tart and can of cola; Lunch- a slice of pizza, chocolate chip cookie, can of cola; Dinner- fried chicken, green beans, biscuit, can of cola; snacks, including cookies and can of cola. She broke up last week with her boyfriend, and he is not aware she might be pregnant. She wants to keep the baby but has not told her parents. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: 1. 17-year-old female reports two missed periods. 2. Reported some spotting last week 3. C/O breast tenderness, swelling, increased frequent in urination, and a.m. nausea 4. (+) pregnancy test 5. Provider has ordered urinalysis and pre-natal lab panel -These are all presumptive signs of pregnancy. RELEVANT Data from Social History: Clinical Significance: 1. Senior in H/S. 2. Works in a job that requires constant standing 3. Denies use of alcohol/nicotine & is not on any prescription medications 4. Reports a daily diet of poor nutritional value 5. Does not currently have a support system, as she has not informed anyone of her present situation -Patient is in stable health with no known major medical concerns at this point. We know that she will need her nutrition and dietary habits addressed to successfully accommodate a growing fetus. She will also need a support system and education on what to expect in the coming months. We’ll know more when her lab panel comes back. Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 98.6 F/37.0 C (oral) Provoking/Palliative: Breast tenderness P: 76 (regular) Quality: Tender to touch and movement R: 18 (regular) Region/Radiation: Both breasts BP: 125/80 Severity: 4/10 but better if wears a bra O2 sat: not assessed Timing: For the past couple of months What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: 1. Temp, HR, & RR are all within expected/acceptabl e ranges 2. BP is on the upper end of acceptable -There really is no significance to her first three VS, but her BP being on the higher end of acceptable is mildly concerning. Considering how young she is and that she isn’t overweight and doesn’t have any other diagnosed medical conditions, we’d like to see that number be a little lower; especially because as she progresses further into the pregnancy we know that BP will continue to rise. So with her current baseline, she’s at an increased risk of having a BP that’s excessively high later on down the line. Current Assessment: GENERAL APPEARANCE: Calm, body relaxed, no grimacing, appears to be slightly nervous, Height 5’4” (160 cm), weight 100 lbs. (45.5 kg), 5 lbs. (2.3 kg) weight loss from pre-pregnant weight, no appetite. BMI 18 RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial, brisk cap refill NEURO: Alert and oriented to person, place, time, and situation (x4) HEENT: Normal cephalic, slight bleeding at gum lines. Conjunctiva of eyelids; appears pale Chest: Breasts tender on palpation, areola darkened and occasional veins present Abdomen: Soft; no masses, uterus palpable below the level of the symphysis pubis, Extremities: Mild spider varicose veins on the medial aspect of the left leg, deep tendon reflexes 2+ Pelvic Exam: Vagina and cervix deep purple in color, uterus slightly enlarged, and Hagar’s sign present What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT Assessment Data: Clinical Significance: 1. She’s had a 5lb weight loss since pregnancy 2. She reports some bleeding at the gums 3. Her conjunctiva is pale a. Breasts tender b. Varicose veins—lower extremity c. Purple cervix/ + Hagar’s sign -Her weight lost is concerning, especially since she was so thin to begin with. We already know she has a poor diet that lacks many of the basic nutrients that she and her baby will need -Bleeding of the gums is a common issue during pregnancy, however, it’s one that needs to be addressed. She is more susceptible to plaque buildup with leads in inflammation and bleeding. We’ll need to make sure she focuses more on oral care as far as brushing and flossing her teeth are concerned -The paleness of her conjunctive makes me think we’re looking at some anemia here, especially with the pregnancy and her nutritional history -The other assessment findings are expected and of no concern at this point Lab Results: Prenatal Panel Hemoglobin RPR/VDRL HBsAG Blood type Rubella HCG ELISA Current: 11.0 mg/dL Negative Negative B- Nonimmune 20,700 mlU/ml Negative What lab results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/ Worsening/ Stable: 1. All these labs are relevant; however, there are some that will need to be addressed. a. Hemoglobi n b. – Rh status c. – neg immunity to Rubella -Her hemoglobin is slightly lower than the expected range in 1st trimester pregnancies. However, since she is pregnant we know that this is something that continue to be depleted with the increased 02 needs of the fetus. It’s important to make sure we can have those levels as high as possible to prepare for this. This can be accomplished by diet and by the use of vitamins as well. -Although, there really isn’t anything we’re going to do with her Rh- status, it needs to be noted -We also can so anything with her lack of immunity to Rubella except remind her to stay away from those that have the disease and urge her to get the vaccine right after she delivers while still in the hospital -This is her initial set of labs, so we have established a baseline for her going forward but not a trend at this point Urine Dipstick Color: Clarity: Sp. Gr. Protein Glucose Ketones Leukocytes/Nitrite Blood Chlamydia Gonorrhea Current: Yellow Clear 1.010 neg neg neg none none positive What lab results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: 1. Urine specific gravity 2. + C/G result -Her urine dipstick didn’t reveal to many concerning findings; although, her urine specific gravity is quite high meaning she may not be hydrating herself enough -And her chlamydia/gonorrhea screen came back positive, so we’re going to need to address that and also make sure this isn’t something that she exposes herself to again in the future Lab Planning: Creating a Plan of Care with a PRIORITY Lab (Reduction of Risk Potential/Physiologic Adaptation) Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: HGB: 11.0 Critical Value: -This low hemoglobin value puts the patient at risk for anemia. Since Hg equals a decreased amount of RBCs, this means there is less 02 to circulate for both mom and baby -explain to the patient to role of hemoglobin for her and her baby and inform her of the results of her blood test -provide supplementation in the way of vitamins - possibly consider IV iron if needed -educate patient on dietary sources of iron so that she can increase her daily intake of those particular items Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: Chlamydia Gonorrhea POSITIVE Critica l Value: -This is a significant finding. It’s important that we address this. Left intreated, this can lead to lower birth weights and pre-term labor. -We need to make sure we treat the infection successfully and also obtain follow up testing after treatment to ensure there is no evidence of infection -Education also needs to be provided on safe sex practices so as to not become re-infected prior to delivery Clinical Reasoning Begins… 1. Interpreting relevant clinical data, what is the primary concern? What primary health related concepts does this primary problem represent? (Management of Care/Physiologic Adaptation) Problem: Physiology of Changes in OWN Words: Primary Concept: -Our primary concern at this point is the patient’s poor diet and nutrition status -As the fetus grows, more and more energy and nutrients are needed to provide and environment that is suitable for this growth. -Things like protein, glucose, iron, and oxygen are necessary components to this successful growth, and most of this comes from our diet. -It’s important to consume foods that foster that growth and supplement what we can’t get from our diet in the