Case Study 1 My Questions are 1.

Case Study 1 My Questions are 1. SOLUTION AND ACTION (must be in relation to the three nursing diagnosis) For each diagnosis prioritize a list of your interventions. Support your interventions and prioritization with full rationales of why they were chosen. 2. EVALUATION/Discussion What are your expected outcomes? In addition to current problems, what will you be alert to in subsequent visits. 3. What needs to be followed up during the postpartum period of this patient. Introduction This patient is a 32-year-old G1P0. She is at her 39 weeks of gestation. She is admitted for having irregular painful contractions all day. On admission her vital signs are T=37C, HR=92, RR=20 bpm, BP=106/64 and oxygen saturation of 99%, Hgb= 11.5, Hct= 34, platelets 200,000, Coombs test negative and her blood type is A. Sterile vaginal exam was done 15 minutes after her admission, the cervix was 3 centimeter dilated, 80% effaced and -1 station, ROA (right occiput anterior). A small amount of clear fluid was noted on the patient’s perineum and the blue chuck. Nitrazine test was conducted, and the strip turned blue, a pH range of 6.5 – 7.0. This is more likely to indicate the membrane has ruptured. At admission, her fetal tracing had a baseline of 140 with moderate variability and minimum accelerations and a reactive strip. Her contraction duration is around 40 – 60 seconds and frequency is between 2 – 3 minutes. The patient states that contractions have been regular for approximately 4 hours. At 2:30 am the patient was given Fentanyl 100mcg IVP for pain and 30 minutes after the patient states the pain relief is inadequate and asked for an epidural. Around 3:00am her cervix was re-examined and progress well, her cervix is 7 centimeters dilated, 100% effaced and at 0 station, ROA and moderate amount of bloody show noted. Her vital signs at this time are as follows T=37C, HR=98, RR=26 bpm, BP=112/68 and oxygen saturation of 99%. At 3:20am the patient started 500cc bolus of IV fluid and the anesthesiologist placed an epidural for pain relief. 20 minutes following the epidural the patient denies pain and her vital signs are T=37C, HR=98, RR=16 bpm, BP=90/48 and oxygen saturation of 97%. The fetal tracing had a baseline of 140 with moderate variability and late deceleration. Analysis Normal findings: Vital signs: T=37C, HR=92 bpm, RR=20 bpm, BP=106/64 mmHg are all within normal range, and oxygen saturation of 99% shows adequate oxygenation. Blood test results: Hgb= 11.5 g/dL, Hct= 34%, platelets 200,000/mm3, and Coombs test negative indicates the mother has no antibodies present against red blood cells of the baby. Fetal tracing: baseline of 140 bpm with moderate variability and minimum acceleration indicates normal fetal heart rate pattern. Sterile vaginal exam: cervix 3 cm dilated, 80% effaced and -1 station indicating the beginning of labor, ROA is expected fetal position. Nitrazine test: strip turned blue with a pH of 6.5 – 7 indicating membrane rupture good progress of labor. Abnormal findings: Irregular painful contractions all day (painful contractions can be a sign of labor, but the irregularity may indicate an issue with contractions or fetal distress). Moderate amount of bloody show (may indicate dilation and cervical effacement, but excessive or bright red bleeding may be concerning for cervical or vaginal injury or other problems). Late deceleration on fetal tracing (indicating potential fetal distress). Fentanyl 100mcg IVP for pain relief was inadequate (may indicate a higher level of pain or other pain management issues). Vital signs after epidural placement: HR=98 bpm, RR=16 bpm (increased heart rate and decreased respiratory rate, which can be side effects of epidural anesthesia). Oxygen saturation of 97% is slightly lower than the previous (99%), may indicate decreased oxygenation and should be monitored closely. Information missing: Patient’s medical history, including any prior pregnancies or complications. Reason for the irregular contractions and the cause of the late decelerations on fetal tracing. Details on the administration of the epidural and any potential side effects. Why this information is needed: A patient’s medical history can provide important context for understanding any prior pregnancy-related issues and can help inform the current treatment plan. Understanding the cause of the irregular contractions and late decelerations on fetal tracing can help determine if there are any potential issues with the pregnancy or fetal wellbeing. Details on the administration of the epidural and potential side effects can help ensure that the patient is receiving appropriate pain management and that there are no adverse reactions. To obtain the missing information, I will: Review the patient’s medical records, including prenatal care and previous obstetrical history, if available. Ask the patient about any previous pregnancies, complications, and medical history. Conduct additional fetal monitoring, such as fetal scalp electrode or non-stress test, to assess fetal wellbeing and identify the cause of the late deceleration. Ask the anesthesiologist for details on the administration of the epidural and any potential side effects. Consult with the patient’s obstetrical care provider to discuss the overall status of the pregnancy and any potential concerns. Prioritize/ Solution/ Action 1-Acute Pain related to uterine contractions and cervical dilation of active labor Explanation: The patient is experiencing irregular and painful contractions and has requested pain relief through an epidural. Pain during labor and delivery is a common experience for many women and can have a significant impact on their physical and emotional wellbeing. Pain can be caused by contractions and cervical dilation, both of which are necessary for progress in labor. This diagnosis was prioritized as the first concern because the patient is experiencing regular and painful contractions which may be a sign of active labor. Pain relief is essential to ensure the patient’s comfort and prevent further distress. The pathophysiology of this diagnosis is due to the uterine contractions causing tension on the uterine muscles and surrounding tissues, leading to discomfort and pain. Impact: Chronic pain during labor and delivery can lead to increased anxiety and stress, decreased mobility, and potential complications such as uterine hyperstimulation or fetal distress. Additionally, pain can also result in decreased maternal satisfaction with the birth experience. In some cases, chronic pain can result in a request for pain management interventions such as epidurals, which can have potential side effects and impact maternal and fetal wellbeing. 2-Impaired Fetal Oxygenation related to late decelerations on fetal tracing Explanation: The fetal tracing shows moderate variability and late decelerations, which can indicate decreased oxygenation to the fetus. This can be caused by a variety of factors, including fetal distress, cord prolapse, or uteroplacental insufficiency. Late decelerations are a concerning sign as they indicate decreased oxygenation to the fetus, which can result in fetal hypoxia. This diagnosis was prioritized as second because it indicates that the fetus may not be receiving enough oxygen, which can cause harm or even fetal distress. It is critical to monitor the fetus and take action to correct any potential issues. The pathophysiology of this diagnosis is due to late deceleration in the fetal heart rate, indicating a decrease in oxygenated blood to the fetus and potentially leading to fetal distress. Impact: Decreased fetal oxygenation can lead to hypoxia, which can result in fetal morbidity and/or mortality. Hypoxia can result in decreased fetal heart rate variability and late decelerations on the fetal tracing. Additionally, fetal hypoxia can lead to long-term effects such as developmental delays or cognitive impairment. It is essential to monitor the fetus for signs of decreased oxygenation and take appropriate interventions to prevent fetal hypoxia. 3-Risk for Fluid Volume Deficit related to 500cc bolus of IV fluid administration Explanation: The patient was given a 500cc bolus of IV fluid, which can rapidly increase fluid volume in the circulatory system and lead to a potential fluid volume deficit. Rapid fluid administration can result in decreased intravascular volume and decreased perfusion to vital organs. This diagnosis was prioritized as third because it may affect the patient’s blood pressure and fluid levels. If left unmonitored and uncontrolled, it can lead to complications such as maternal hypotension or pre-eclampsia. The pathophysiology of this diagnosis is due to the administration of a 500cc IV fluid bolus, which can cause a rapid increase in fluid levels and affect electrolyte balance. The patient’s blood pressure, fluid levels, and electrolyte levels must be closely monitored and controlled. Impact: A fluid volume deficit can result in decreased perfusion to vital organs, decreased blood pressure, and potential electrolyte imbalances, which can have a negative impact on both the mother and fetus. In severe cases, a fluid volume deficit can result in decreased cardiac output and shock, which can be life-threatening for both the mother and fetus. It is essential to monitor the patient’s fluid status and intervene as necessary to maintain fluid balance. My Questions are 1. SOLUTION AND ACTION (must be in relation to the three nursing diagnosis) For each diagnosis prioritize a list of your interventions. Support your interventions and prioritization with full rationales of why they were chosen. 2. EVALUATION/Discussion What are your expected outcomes? In addition to current problems, what will you be alert to in subsequent visits. 3. What needs to be followed up during the postpartum period of this patient.

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