NUR1211C: Preeclampsia-Eclampsia RAPID Reasoning,Dana Myers, 40 years old (Answered)

Preeclampsia-Eclampsia RAPID Reasoning Dana Myers, 40 years old Primary Concept Intracranial Regulation Interrelated Concepts (In order of emphasis) 1. Perfusion 2. Reproduction 3. Clinical Judgment © 2016 Keith Rischer/www.KeithRN.com RAPID Reasoning Case Study: STUDENT Preeclampsia-Eclampsia History of Present Problem: Dana Myers is a 40-year-old woman, G-3 P-2 who is 34 weeks gestation. Her health care provider has been monitoring her weekly because her blood pressure has been increasing the past month and is currently 146/88. Last week she had 1+ non-pitting edema of both lower extremities (BLE) and her urine was negative for protein. Today during her clinic visit, Dana’s BP was 168/90. She had 2+ proteinuria and 3+ pitting edema BLE. She also complained of a mild headache in the center of her forehead, and seeing “spots.” Fetal heart tones via Doppler are 136/minute in the lower left quadrant. Abdominal measurement from pubic bone to top of fundus is 31 cm. The primary care provider was concerned and Dana has been admitted to the community hospital labor and delivery unit to be evaluated for severe preeclampsia. You are the admitting nurse responsible for her care. Personal/Social History: Dana has two children, ages two and four. She is married and both she and her husband are excited to have another baby, but have been concerned about this pregnancy. Dana’s previous two pregnancies were healthy, without incident, resulting in the vaginal births of a boy, then a girl. Dana’s parents live in the same town and are supportive. Dana works part-time teaching English at the local community college. Her husband is an engineer who works full time and is occasionally out of town for work. Dana is generally healthy, without any chronic illnesses. She does not smoke or use recreational drugs. She reports drinking socially but refrains while pregnant. What data from the histories are RELEVANT and has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: Increasing blood pressure. +2 proteinuria Pitting edema BLE Mild headache in the center of forehead and seeing spots. These are all manifestations of preeclampsia. RELEVANT Data from Social History: Clinical Significance: Two children ages 2 and 4. Married. Parents live in same town. Part-time teaching English. Husband engineer. Dana already has two younger children, which could be stressful with being pregnant and having complications. With Dana being married and having her parents living in the same town, shows that she has a good support system. Dana works part-time and her husband is an engineer, so they are financially stable. Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 98.4 F/36.9 C (oral) Provoking/Palliative: None P: 84 (regular) Quality: Stabbing/throbbing R: 20 (regular) Region/Radiation: Eyes, forehead BP: 164/98 Severity: 5/10 O2 sat: 95% room air Timing: Constant, unrelieved by acetaminophen What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: BP:164/98 Constant, stabbing, throbbing pain in eyes and forehead and is unrelieved by acetaminophen. High blood pressure is related to preeclampsia. Headaches and vision changes can be associated with CNS irritation or could indicate cerebral edema. Website. “Preeclampsia - Signs-And-Symptoms.” Preeclampsia Foundation - Helping Save Mothers and Babies from Illness and Death Due to Preeclampsia, Current Assessment: GENERAL APPEARANCE: Appears uncomfortable RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort CARDIAC: Pink, warm/dry, 3+ non-pitting edema of BLEs with generalized edema of hands, face, and sacrum, 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). Reflexes are brisk with no clonus, c/o headache and continues to see “spots” GI: Abdomen soft/non-tender, slight epigastric discomfort, bowel sounds audible per auscultation in all four quadrants, no contractions palpated, uterus soft. GU: Voiding without difficulty, urine clear/yellow, urine 2+ by dipstick. SKIN: Skin integrity intact What assessment data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: 3+ non-pitting edema of BLEs Generalized edema of hands, face, and sacrum. Slight epigastric discomfort. Urine 2+ by dipstick. Due to fluid retention in the body’s tissues. Epigastric gastric pain could be related to many different factors. It is also a manifestation of preeclampsia. Non-stress Test What results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Results: Clinical Significance: The non-stress test is non- reactive. Fetal heart rate baseline 130, with minimum variability and no accelerations. No decelerations are noted. Non-stress test non-reactive indicates baby did not make the minimum number of movements for the time period. Baby could be sleeping. Fetal heart rate is normal with minimal fluctuation in heart rate. Lab Results: Complete Blood Count (CBC:) Current: High/Low/WNL? Previous: WBC (4.5–11.0 mm 3) 5,000-15,000 14.8 WNL 14.5 Hgb (12–16 g/dL) Pregnancy: 11.5-14 11.3 Low 11.4 Platelets (150-450 x103/µl) 72 LOW 115 Neutrophil % (42–72) 70 WNL 68 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Hgb Platelets Hgb is low but not by much. Hgb need to be monitored to observe for a decreasing trend. Low platelet count could indicate HELLP syndrome. Worsening Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Previous: BUN: (7–25 mg/dl) Pregnant: (3-11mg/mL) 33 High 11 Creatinine: (0.6–1.2 mg/dL) Pregnant: 0.4-0.9 mg/mL 2.1 High 1.4 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: BUN Creatinine BUN and Creatinine are elevated. Higher creatinine levels usually indicate fluid volume deficit or renal involvement in preeclampsia. Manaj, Aferdita, et al. “The Impact of Preeclampsia in Pregnancy.” Journal of Prenatal Medicine, CIC Edizioni Internazionali, Jan. 2011, Worsening Liver Function Test (LFT:) Current: High/Low/WNL? Previous: Albumin (3.5–5.5 g/dL) 4.5 WNL 4.7 Total Bilirubin (0.1–1.0 mg/dL) 0.5 WNL 0.6 Alkaline Phosphatase male: 38–126 U/l female: 70–230 U/l 122 WNL 90 ALT (8–20 U/L) 20 WNL 18 AST (8–20 U/L) 18 WNL 20 LDH (90-156 units/L) 98 WNL 90 RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Alkaline phosphatase All labs are within normal limits. Alkaline phosphatase is increasing. Needs to be monitored. Could be related to HELLP syndrome. C. Delluc, N. Costedoat-Chalumeau, D. Saadoun, D. Vauthier- Brouzes, B. Wechsler, J.-C. Piette, Elevation of alkaline phosphatase in a pregnant patient with antiphospholipid syndrome: HELLP syndrome or not?, Rheumatology, Volume 47, Issue 4, April 2008, Pages 554–555, Urine Analysis (UA:) Current: WNL/Abnormal? Previous: PCR 4.3 Abnormal n/a What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: PCR Identifies how much protein is in the urine. High amounts of protein indicates preeclampsia. Not enough data to compare. Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting? Preeclampsia 2. What is the underlying cause/pathophysiology of this primary problem? Preeclampsia is a placental disease that has two stages. Stage 1 is abnormal placentation in the first trimester followed by stage 2, a maternal syndrome that takes place in the late 2nd trimester or 3rd trimester. It is characterized by an excess of antiangiogenic factor. Uteroplacental ischemia drives the hypertensive, multi-organ failure response observed in the maternal preeclamptic syndrome. Rana, Sarosh, et al. “Preeclampsia.” Circulation Research, 28 Mar. 2019, (Relate initial manifestations to the pathophysiology of the primary problem) Pathophysiology of Primary Problem: Rationale for Manifestations: Increasing BP Proteinuria Changes in vision Upper abdominal pain Impaired liver function Thrombocytopenia Edema to face and hands Hypertension (the second manifestation of PIH after edema) occurs owing to increased sensitization to angiotensin II, which increases BP, promotes aldosterone release to increase sodium/water reabsorption from the renal tubules, and constricts blood vessels. May be associated with CNS irritation or be an indication of cerebral edema. Proteinuria affects fluid shifts from the vascular tree. Caused by swelling of the liver resulting in epigastric pain. Elevated liver enzyme and thrombocytopenia may indicate presence of HELLP syndrome, signifying a need for immediate cesarean delivery if condition of cervix is unfavorable for induction of labor. The presence of pitting edema (mild, 1+ to 2+; severe, 3+ to 4+) of face, hands, legs, sacral area, or abdominal wall, or edema that does not disappear after 12hr of bedrest is vital. Wayne, Gil, et al. “6 Pregnancy Induced Hypertension Nursing Care Plans.” Nurseslabs, 1 June 2019, Website. “Preeclampsia - Signs-And-Symptoms.” Preeclampsia Foundation - Helping Save Mothers and Babies from Illness and Death Due to Preeclampsia, Collaborative Care: Medical Management Care Provider Orders: Rationale: Expected Outcome: Labetolol 20 mg IV x1 Magnesium sulfate 4 g IV bolus (40 g in 1000 mL LR) followed by continuous IV infusion at 2 g/hour To treat elevated blood pressure. To help treat elevated blood pressure as well as seizure prevention. Patient BP will decrease to baseline and patient’s probability of experiencing a seizure will decrease. To speed up the development of baby’s lungs. Betamethasone 12 mg IM Prepare for induction of labor Continuous fetal monitoring Seizure precautions Preeclampsia is life threatening to mom and baby. Life saving measures need to be taken. Preeclampsia is not cured until the baby is delivered. Helps to evaluate fetal wellbeing, so that accelerations and/or decelerations are noted. To ensure safety of mother and to prevent injuries. PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Order of Priority: Rationale: • Seizure precautions • Labetalol 20 mg IV x1 now Labetalol 20 mg IV x1 now Magnesium sulfate 4 g IV You want to treat the high blood pressure first by administering labetalol and magnesium sulfate. An extremely high blood pressure could be life threatening to mom and • Magnesium sulfate 4 g IV bolus (40 g in 1000 bolus (40 g in 1000 mL LR) followed by continuous IV baby. mL LR) followed by infusion at 2 g/hour Magnesium sulfate can stop or slow preterm labor and prevent seizure due to preeclampsia. Cheryl Bird, RN. “Magnesium Sulfate and Premature Labor.” Verywell Family, continuous IV infusion at 2 g/hour Betamethasone 12 mg IM Seizure precautions Betamethasone is given to help speed up development of the baby’s lungs. Treat mother first and then intervene to save baby. • Continuous fetal monitoring • Betamethasone 12 mg IM Continuous fetal monitoring Seizure precautions to keep mom safe from injury. Continuous fetal monitoring to monitor fluctuating HR. intervene if HR becomes too low. Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (if more than one-list in order of PRIORITY) Maintain BP, implement seizure precautions for patient safety. 4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale: Expected Outcome: Monitor BP. Monitor I&Os. Pad side rails of the bed. Be sure suction is set up. Bedrest with patient in left lateral position. Note signs of progressive or excessive edema i.e., epigastric/RUQ pain, cerebral symptoms, nausea, vomiting). Assess for possible eclampsia. An increase in BP is a serious sign of preeclampsia. increased sensitization to angiotensin II, which increases BP, promotes aldosterone release to increase sodium/water reabsorption from the renal tubules, and constricts blood vessels. Urine output is a sensitive indicator of circulatory blood volume. Oliguria and specific gravity of 1.040 indicate severe hypovolemia and kidney involvement. To keep patient safe from head injury. To prevent aspiration. Improves venous return, cardiac output, and renal/ placental perfusion. Edema and intravascular fibrin deposition (in HELLP syndrome) within the encapsulated liver are manifested by RUQ pain; dyspnea, indicating pulmonary involvement; cerebral edema, possibly leading to seizures; and nausea and vomiting, indicating GI edema. Wayne, Gil, et al. “6 Pregnancy Induced Hypertension Nursing Care Plans.” Nurseslabs, 1 June 2019, 5. What body system(s) will you assess most thoroughly based on the primary/priority concern? Cardiovascular, neuro, and genitourinary. 6. What is the worst possible/most likely complication to anticipate? HELLP syndrome 7. What nursing assessments will identify this complication EARLY if it develops? Assess platelet count, Hgb, and liver enzymes. Assess for headaches and right upper gastric pain, which is associated with HELLP. Assess BP and obtain a urinalysis. 8. What nursing interventions will you initiate if this complication develops? Bedrest with close monitoring, continuous fetal monitoring, administer Magnesium sulfate per doctor’s orders, administer BP medication per doctor’s orders, continuous BP monitoring, administer corticosteroids to help expedite baby’s lung development. “HELLP Syndrome.” American Pregnancy Association, 27 Aug. 2020, 9. What psychosocial needs will this patient and/or family likely have that will need to be addressed? Involve the patient and family in care, address patient’s fear and any concerns patient and family may have. How can the nurse address these psychosocial needs? The nurse can provide guidance on how to deal with emotions in a healthy way. The nurse can educate the patient on what signs to look for related to preeclampsia and when to call her provider because postpartum preeclampsia is a possibility, although it is rare. The nurse should utilize proper communication techniques. Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation? The patient is probably scared, worried, and anxious. She might fear that something might happen to her baby and/or to herself. In these types of situations, mothers worry more about the well being of their child rather than themselves. 2. What can you do to engage yourself with this patient’s experience, and show that he/she matter to you as a person? You can relieve an anxiety by keeping the patient and family involved. Keep the patient updated about the progress of the baby. The mother does not know how to interpret the information on the monitor. Explain every procedure before performing them. Keep open communication. Answer any questions of concerns the patient may have in a timely manner. Be attentive and listen to what the patient has to say. Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment. 1. What did I learn from this scenario? I learned about the lab PCR. I did not know what it was before doing this scenario. I learned the normal value and what it is used to detect. 2. How can I use what has been learned from this scenario to improve patient care in the future? I will know what interventions to implement for a patient that has preeclampsia. I will know what labs to monitor in relation to preeclampsia. I will know what signs look for if the patient declines and develops HELLP syndrome.