PERINATAL UNFOLDING CASE STUDY 1 Tanya Carmichael MSN

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PERINATAL UNFOLDING CASE STUDY 1 Tanya Carmichael, MSN, RNC Christina Harkins, MSN, RNC Mary

PERINATAL UNFOLDING CASE STUDY 1 Tanya Carmichael, MSN, RNC Christina Harkins, MSN, RNC Mary Lou Gies, Ed. D, RN La Salle University

INITIAL PRENATAL VISIT You are a registered nurse (RN) working in a Women’s Health

INITIAL PRENATAL VISIT You are a registered nurse (RN) working in a Women’s Health Clinic. Mary Johnson, 38 years old, presents to the prenatal clinic after missing her last 2 menstrual cycles. Her home pregnancy test was positive. An ultrasound at the clinic confirms pregnancy. Gestational age is calculated to be 10 weeks. An initial assessment of Ms. Johnson’s medical and obstetrical history follows. 2

HISTORY Obstetric/Gynecologic (OB/GYN) history (hx): Uncomplicated spontaneous vaginal delivery (SVD) at 38. 2 weeks

HISTORY Obstetric/Gynecologic (OB/GYN) history (hx): Uncomplicated spontaneous vaginal delivery (SVD) at 38. 2 weeks (5 years ago); Cesarean section (C/S) x 1 at 37. 5 weeks for non-reassuring fetal heart tones (FHT) (3 years ago); abnormal Papanicolaou (PAP) smear x 1, + human papilloma virus (HPV), colposcopy within normal limits (WNL); Chlamydia with treatment (7 years ago) Medical hx: Chronic hypertension (HTN) x 5 years; asthma no intubations or hospitalizations; hx of breast biopsy, benign (2 years ago) Allergies: Penicillin 3

HISTORY Social hx: (+) tobacco, “occasional” per patient (pt), <5 per/day currently, has smoked

HISTORY Social hx: (+) tobacco, “occasional” per patient (pt), <5 per/day currently, has smoked “off and on” for 15 years (+) cocaine use, states she has not used any cocaine/drugs for > 1 year; (-) alcohol use Abusive partner with first pregnancy, states she has a new partner x 4 years Depression, currently not taking meds for treatment (tx) Medications: Prenatal vitamins; Labetalol 200 mg BID; Albuterol inhaler as needed (prn) Family hx: Insulin-dependent diabetes mellitus (mother); HTN and heart disease (father); lung cancer (CA) (maternal grandmother, deceased) 4

What should the nurse consider related to caring for a patient with a history

What should the nurse consider related to caring for a patient with a history of domestic abuse, drug use, sexually transmitted diseases and depression? 5

Professional nurses should be aware of attitudes, values and beliefs that they hold related

Professional nurses should be aware of attitudes, values and beliefs that they hold related to patients from different social backgrounds so that care is not affected negatively. QSEN: KSA (next slide) 6

QSEN KSA: PATIENT CENTERED CARE KNOWLEDGE: Review patient support system and resources SKILL: Refer

QSEN KSA: PATIENT CENTERED CARE KNOWLEDGE: Review patient support system and resources SKILL: Refer patient to appropriate resources r/t domestic abuse and addiction as indicated ATTITUDE: Recognize personally held attitudes about working with patients from different ethnic, cultural and social backgrounds; willingly support patient-centered care for individuals and groups whose values differ from own 7

INITIAL PRENATAL VISIT Vital Signs (VS): Temp 98. 10 F, RR 20, HR 86,

INITIAL PRENATAL VISIT Vital Signs (VS): Temp 98. 10 F, RR 20, HR 86, BP 142/79 WHAT LABORATORY AND ASSESSMENT DATA SHOULD BE COLLECTED DURING THIS VISIT? AFTER CONSIDERING THE INFORMATION PROVIDED, WHAT OTHER ASSESSMENTS AND ISSUES NEED TO BE ADDRESSED DURING THIS PRENATAL VISIT? 8

WHAT LABORATORY AND ASSESSMENT DATA SHOULD BE COLLECTED DURING THIS VISIT? LAB DATA: Complete

WHAT LABORATORY AND ASSESSMENT DATA SHOULD BE COLLECTED DURING THIS VISIT? LAB DATA: Complete blood count (CBC) Blood type and Rh Rh antibody screen Gonorrhea and Chlamydia cultures Serology - Syphilis (RPR or VDRL) Rubella Hepatitis B surface antigen HIV testing (offer test; provide pretest counseling) Urine drug screen (UDS) ASSESSMENT DATA: Baseline VS: pay special attention to BP – pt with hx of HTN Weight: 150 lbs FHR (from doptone or ultrasound): 145 Baseline review of systems assessment 9

LABORATORY VALUES WHAT IS THE SIGNIFICANCE OF THESE LAB VALUES? Determination Patient Result Reference

LABORATORY VALUES WHAT IS THE SIGNIFICANCE OF THESE LAB VALUES? Determination Patient Result Reference / Normal Hemoglobin (Hgb) 12. 7 g/d. L Female: 12 -16 g/d. L Hematocrit (Hct) 37% Female: 40%-48% White Blood Cell Count (WBC) 9, 000 5000 -10, 000/mm³ Blood type and Rh A- N/A Rh antibody screen + _ Gonorrhea & Chlamydia cultures _ _ Serology (RPR, VDRL) _ _ Rubella Immune HIV _ _ UDS _ _ Hepatitis B surface antigen _ _ Reference: Pagana, K. D, & Pagana, T. J. (2003) Diagnostic & Laboratory Test Reference, , 6 th Ed. Mosby, Inc. : St. Louis, MO 10

AFTER CONSIDERING THE INFORMATION PROVIDED, WHAT OTHER ASSESSMENTS AND ISSUES NEED TO BE ADDRESSED

AFTER CONSIDERING THE INFORMATION PROVIDED, WHAT OTHER ASSESSMENTS AND ISSUES NEED TO BE ADDRESSED DURING THIS PRENATAL VISIT? Safety Screening: Pt has a history of an abusive partner, depression and drug use. Psychosocial assessment (including domestic violence) and depression / suicide risk would be important during this first visit. Smoking history: council pt. on smoking cessation. QSEN KSA: Safety Skill: Use appropriate strategies, such as Psychosocial Screening Tool (slide 13) and Depression/Suicide Risk Assessment (slide 15): to reduce reliance on memory when assessing the patient’s risk to reduce risk of harm to self or others 11

PSYCHOSOCIAL SCREENING TOOL Do you have any problems (jobs, transportation, etc) that prevent you

PSYCHOSOCIAL SCREENING TOOL Do you have any problems (jobs, transportation, etc) that prevent you from keeping your health care appointments? Do you feel unsafe where you live? During the past year, has anyone hit you or tried to hurt you? Do you or any members of your household go to bed hungry? How do your rate your current stress level- low or high? How many times have you moved in the past 12 months? In the past 2 months, have you used any form of tobacco, drugs, or alcohol? If you could change the timing of this pregnancy, would you want it earlier, later, not at all, or no change? Adapted from: ACOG Committee Opinion, No. 343. (August, 2006). Psychosocial risk factors: Perinatal screening and intervention. Obstetrics and Gynecology, 108(2), 469 -477. 12

DEPRESSION/SUICIDE RISK ASSESSMENT As the RN working with Ms. Johnson how often would you

DEPRESSION/SUICIDE RISK ASSESSMENT As the RN working with Ms. Johnson how often would you assess her psychosocial status, level of depression and risk for suicide? According to ACOG, screening should be performed AT LEAST once each trimester. Problems may arise during the pregnancy that were not present at the initial visit. What questions would you ask her? 13 ACOG Committee Opinion, No. 343. (August, 2006). Psychosocial risk factors: Perinatal screening and intervention. Obstetrics and Gynecology, 108(2), 469 -477.

DEPRESSION / SUICIDE RISK ASSESSMENT Depression Risk Questions: Over the past 2 weeks, have

DEPRESSION / SUICIDE RISK ASSESSMENT Depression Risk Questions: Over the past 2 weeks, have you ever felt down, depressed, or hopeless? Over the past 2 weeks, have you felt little interest or pleasure in daily activities? Suicide Risk Questions: Do you have thoughts of injuring yourself? Do you have thoughts of killing yourself? (If yes) Do you have a plan? 14

DEPRESSION Untreated depression has been associated with unfavorable health behaviors in pregnancy and may

DEPRESSION Untreated depression has been associated with unfavorable health behaviors in pregnancy and may contribute to: Fetal growth restriction Preterm delivery Placental abruption Newborn irritability 15 ACOG Committee Opinion, No. 343. (August, 2006). Psychosocial risk factors: Perinatal screening and intervention. Obstetrics and Gynecology, 108(2), 469 -477.

RISK FACTORS Ms. Johnson is at greater risk for which pregnancy complications as a

RISK FACTORS Ms. Johnson is at greater risk for which pregnancy complications as a result of her medical and social history? 16

RISK FOR PREGNANCY COMPLICATIONS Ms Johnson’s medical and social history puts her at higher

RISK FOR PREGNANCY COMPLICATIONS Ms Johnson’s medical and social history puts her at higher risk for: Preeclampsia Low birth weight infant Preterm labor &/or preterm birth Intrauterine growth restriction Spontaneous abortion Placental abruption 17

TEACHING What are the priority teaching points to discuss with Ms. Johnson before she

TEACHING What are the priority teaching points to discuss with Ms. Johnson before she leaves the clinic today? QSEN KSA: Patient Centered Care Knowledge: Integrate understanding of multiple dimensions of patient- centered care, i. e. information, communication, and education 18

TEACHING Signs/symptoms of preeclampsia, preterm labor and abruption Information and resources for support related

TEACHING Signs/symptoms of preeclampsia, preterm labor and abruption Information and resources for support related to (r/t) safety at home, depression, suicide, drug use or any other concerns about caring for her self and her family Stress importance of consistent prenatal care throughout the pregnancy Smoking Provide Cessation measures to support quitting 19

SIGNS &SYMPTOMS Preeclampsia Continuous H/A Elevated B/P Edema Epigastric pain Shortness of breath Dizziness

SIGNS &SYMPTOMS Preeclampsia Continuous H/A Elevated B/P Edema Epigastric pain Shortness of breath Dizziness Decreased urinary output Visual disturbances (blurred vision or spots) Preterm Labor Cramping Pelvic pressure Vaginal discomfort Increased vaginal discharge Loss of fluid Vaginal bleeding Feeling “not right” Abruption Vaginal bleeding Abdominal tenderness Low back pain Cramping 20

 Ms. Johnson has been able to come to all but one of her

Ms. Johnson has been able to come to all but one of her scheduled prenatal visits. She has been taking her blood pressure regularly at home and reports a range of 138 -165/72 -90. She has denied symptoms of headache (HA), epigastric pain, visual disturbances, shortness of breath, dizziness. Urine dipstick at clinic visits has shown 0 to trace protein. Her asthma has been stable, with occasional use of her inhaler. She denies use of cocaine, other drugs, and alcohol. She states that she is “trying to smoke only 2 -3 cigarettes / day” but sometimes smokes up to ½ pack on stressful days. 21

TRIAGE VISIT: AFTER A FALL Ms. Johnson is now 27 weeks pregnant. She presents

TRIAGE VISIT: AFTER A FALL Ms. Johnson is now 27 weeks pregnant. She presents to the perinatal triage unit of the hospital reporting that she slipped and fell in the shower. What are the priority nursing assessments at this time? QSEN KSA: Patient-Centered Care Skill: Engage patient or designated surrogates in active partnerships that promote health, safety, and well-being, and self care management. 22

PRIORITY NURSING ASSESSMENTS Maternal VS Fetal heart rate Contractions (ask patient and use tocodynamometer)

PRIORITY NURSING ASSESSMENTS Maternal VS Fetal heart rate Contractions (ask patient and use tocodynamometer) Do you feel fetal movement? How often? Are you having any vaginal bleeding? How many pads have you filled in the last hour? Do you feel any vaginal discharge or leaking? Are you having any abdominal pain or tenderness? Review more specific history related to fall… determine if related to domestic abuse 23

 Assessment data: Maternal VS: BP 154/82, HR 98, RR 20, T 98. 80

Assessment data: Maternal VS: BP 154/82, HR 98, RR 20, T 98. 80 F FHR baseline: 150 with moderate variability; + accelerations noted; occasional variable decelerations noted Occasional contractions: ~ 3 -4/hour + fetal movement No vaginal bleeding or loss of fluid No abdominal pain or tenderness Pt denies HA, visual disturbances, right upper quadrant pain; urine dipstick trace protein Ms. Johnson denies that the fall resulted from any form of domestic violence; states that she does not feel unsafe in her home. 24

RHOGAM After 2 hours of observation with no change in pt status, the physician

RHOGAM After 2 hours of observation with no change in pt status, the physician orders administration of Rho. GAM. Why? What actions does the nurse need to take prior to administering this medication? QSEN KSA: Safety Knowledge: Describe processes used in understanding causes of error and allocation of responsibility and accountability Skill: Demonstrate effective use of technology and standardized practices that support safety and quality 25

RHOGAM Prevents formation of active antibodies against Rh+ erythrocytes which may enter maternal bloodstream

RHOGAM Prevents formation of active antibodies against Rh+ erythrocytes which may enter maternal bloodstream during pregnancy with Rh+ fetus Generally given at 28 weeks. Also given with: Bleeding or suspected hemorrhage Threatened abortion Abdominal trauma Prior to administration: Send current type & screen Indirect Coombs Explain purpose and side effects; answer pt questions Obtain informed consent Verification by 2 RNs 26

 Ms. Johnson is stable at home until 30 weeks gestation. At that time

Ms. Johnson is stable at home until 30 weeks gestation. At that time she is returns to the hospital complaining of vague lower abdominal pain with a gush of vaginal bleeding ~1 ½ hours ago, soaking 2 pads within 2 hours. The bleeding has tapered off to spotting. She reports + nausea and abdominal cramping; pain 3/10. 27

 External fetal monitor (EFM) & Tocodynamometer (TOCO) are applied and show a FHR

External fetal monitor (EFM) & Tocodynamometer (TOCO) are applied and show a FHR baseline of 150, moderate variability, occasional accelerations, no decelerations noted; + uterine irritability noted with mild contractions ~ 3 -4 minutes apart VS: BP 168/82; HR 102; RR 20; T 98. 10 F QSEN KSA: Informatics Skill: Apply technology and information management tools to support safe processes of care; Use high quality electronic sources of healthcare information 28

 What do you suspect may be occurring? Based on the initial assessment, what

What do you suspect may be occurring? Based on the initial assessment, what are the priority nursing interventions for Ms. Johnson? 29

NURSING INTERVENTIONS FOR PLACENTA PREVIA/ABRUPTION Notify MD Explain situation to pt ID and allergy

NURSING INTERVENTIONS FOR PLACENTA PREVIA/ABRUPTION Notify MD Explain situation to pt ID and allergy bands Continuous EFM & TOCO Initiate pad count Urine dipstick Laboratory Type data & screen CBC Coagulation studies Chemistry profile Urine analysis: including UDS Large bore IV and fluids 30 QSEN KSA: Patient Centered Care • Attitude: Value seeing health care situations “through patient’s eyes”

NURSING INTERVENTIONS FOR PLACENTA PREVIA/ABRUPTION Assess patient understanding of plan of care Teach patient

NURSING INTERVENTIONS FOR PLACENTA PREVIA/ABRUPTION Assess patient understanding of plan of care Teach patient to notify RN of any changes Explain procedures, answer questions and offer reassurance Ensure that informed consents for surgery and blood transfusion are on chart Suggest Neonatology consult QSEN: KSA (next slide) 31

QSEN KSA: NURSING INTERVENTIONS FOR PLACENTA PREVIA/ABRUPTION QSEN KSA: Patient-Centered Care Skill: Provide patient-centered

QSEN KSA: NURSING INTERVENTIONS FOR PLACENTA PREVIA/ABRUPTION QSEN KSA: Patient-Centered Care Skill: Provide patient-centered care with sensitivity & respect for the diversity of human experience; Assess own level of communication skill in encounters with patients and families Attitude: Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care QSEN KSA: Teamwork and Collaboration Skill: Demonstrate awareness of own strengths and limitations as a team member Attitude: Acknowledge own potential to contribute to effective team functioning QSEN KSA: Safety Skill: Demonstrate effective use of technology and standardized practices that support safety and quality 32

 Placenta previa ruled out per ultrasound (us). No clots noted on u/s. Speculum

Placenta previa ruled out per ultrasound (us). No clots noted on u/s. Speculum exam confirms ~10 m. L blood in vault, no clots; 1 cm dilated visually. Vaginal bleeding continues: small amounts of occasional bright red spotting on pads. FHTs remain reassuring. + UDS Patient admitted for high risk antepartum surveillance 33

 At 2330, the nurse notes that FHR baseline has increased to 170 with

At 2330, the nurse notes that FHR baseline has increased to 170 with no accelerations, and repetitive late decelerations. Vaginal bleeding has increased, and patient reports sharp abdominal pain (8/10) with uterine tenderness on palpation. Contractions have increased in frequency, ~ 2 -3 min apart and uterus remains firm between contractions. VS: BP 150/72 ; HR 110; RR 22; Temp 97. 90 F; Pulse oximeter (pox) on room air 96% 34

WHAT ARE THE PRIORITY NURSING INTERVENTIONS AT THIS TIME? Notify the physician immediately Plan

WHAT ARE THE PRIORITY NURSING INTERVENTIONS AT THIS TIME? Notify the physician immediately Plan for probable stat cesarean section Call for additional help to prepare for surgery Intrauterine resuscitation IVF bolus, 10 L O 2 via face mask, pt to left lateral position Frequent VS Insert foley catheter & complete shave prep Draw and send blood for type and cross-match; ensure MD order for blood products Explain all interventions to patient and reasons for moving quickly QSEN: KSA (next slide) 35

QSEN KSA: Priority Nursing Interventions for Abruption QSEN KSA: Safety Skill: Demonstrate effective use

QSEN KSA: Priority Nursing Interventions for Abruption QSEN KSA: Safety Skill: Demonstrate effective use of strategies to reduce risk of harm to self and others Attitude: Value own role in preventing errors QSEN KSA: Teamwork and Collaboration Knowledge: Describe own strengths, limitations & values as a team member Skill: Demonstrate awareness of own strengths & limitations as a team member; assume role of team member or leader based on the situation; initiate requests for help when appropriate to situation; integrate contributions of others who play a role in helping patient/family achieve health goals Attitude: Acknowledge own potential contributions to effective 36 team functioning

TO ENSURE MS. JOHNSON’S SAFETY IN THE OPERATING ROOM (OR), WHAT VERIFICATIONS MUST BE

TO ENSURE MS. JOHNSON’S SAFETY IN THE OPERATING ROOM (OR), WHAT VERIFICATIONS MUST BE COMPLETED PRIOR TO TRANSFER? ID band is in place and pt is correctly Identified by 2 identifiers All jewelry, clothing, metal removed Confirm allergies Verify informed consents for surgery and blood transfusion on chart QSEN KSA: Safety Skill: Demonstrate effective use of strategies to reduce risk of harm to self and others 37

 Physician immediately notified and at bedside; pt is 6/90/-1 on vaginal exam with

Physician immediately notified and at bedside; pt is 6/90/-1 on vaginal exam with moderate bright red vaginal bleeding Maternal VS: BP 120/60, HR 108, RR 23, T 99. 40 F, pox 100% on 10 L O 2; patient very anxious FHTs continue to be ominous with repetitive late decelerations Multidisciplinary team mobilized for stat cesarean section 38

OPERATING ROOM In the OR, one RN is responsible for circulating, and you are

OPERATING ROOM In the OR, one RN is responsible for circulating, and you are responsible for baby care and resuscitation, with the team from the neonatal intensive care unit (NICU). The team from the NICU is waiting in the OR and report is given. After a “time out” the patient goes under general anesthesia and the baby is born ~ 3 minutes later. Apgars were 5 at one minute, and 7 at five minutes. QSEN KSA: Safety Skill: Demonstrate effective use of strategies to reduce risk of harm to self others Attitude: Value own role in preventing errors and 39

TRANSFER TO NICU Prior to transfer to the NICU, what priority action must the

TRANSFER TO NICU Prior to transfer to the NICU, what priority action must the NICU nurse take? 40

TRANSFER TO NICU The baby must be properly identified via 2 bands with mother’s

TRANSFER TO NICU The baby must be properly identified via 2 bands with mother’s name, baby’s date and time of birth. Also, footprinting and band ID number should be confirmed by another RN and matching bands applied to mother & significant other prior to transfer to NICU. QSEN KSA: Safety Skill: Demonstrate effective use of strategies to reduce the risk of harm to self or others Attitude: Value the contributions of standardization/reliability to safety; appreciate the cognitive and physical limits of human performance; value own role in preventing errors 41

PATIENT TRANSFER Ms. Johnson is transferred from the OR to the recovery room, and

PATIENT TRANSFER Ms. Johnson is transferred from the OR to the recovery room, and then to the postpartum unit. What should be included in the SBAR report? 42

SBAR REPORT Situation Mom: Name, room #, physician, time/type of delivery, assistive instruments Infant:

SBAR REPORT Situation Mom: Name, room #, physician, time/type of delivery, assistive instruments Infant: gestational age, sex, weight, apgars, feeding type Background Patient prenatal history and history since admission Assessment Mom: vital signs, BUBBLEHEP findings Infant: vital signs, dextrostix, abnormal assessment findings Recommendations Newborn initial eye care, Vitamin K 43 QSEN: KSA (next 2 slides)

QSEN: PATIENT TRANSFER QSEN KSA: Teamwork and Collaboration Skill: Assume role of team member/leader

QSEN: PATIENT TRANSFER QSEN KSA: Teamwork and Collaboration Skill: Assume role of team member/leader based on situation; function competently within own scope of practice as member of health care team; integrate contributions of others who play a role in helping patient/family achieve health goals; follow communication practices that minimize risks associated with handoffs among providers and across transitions QSEN KSA: Patient-centered Care Knowledge: Integrate understanding of multiple dimensions of patient centered care: information, communication, and education 44

QSEN: PATIENT TRANSFER QSEN KSA: Safety Skill: Use appropriate strategies to reduce reliance on

QSEN: PATIENT TRANSFER QSEN KSA: Safety Skill: Use appropriate strategies to reduce reliance on memory Attitude: Value the contributions of standardization/reliability to safety; appreciate the cognitive and physical limits of human performance; value own role in preventing errors QSEN Skill: KSA: Quality Improvement Use tools to make processes of care explicit 45

PATIENT TRANSFER The postpartum nurse does the initial assessment and the patient’s condition is

PATIENT TRANSFER The postpartum nurse does the initial assessment and the patient’s condition is stable. She tells her that her family is in the waiting room, asking to see her. She asks her if she is ready for visitors. Her family arrives and are elated about the new addition to the family! QSEN KSA: Teamwork & Collaboration Knowledge: Recognize contributions of other individuals & groups in helping patient/famlly achieve health goals. Skill: Integrate the contributions of others who play a role in helping patient/family achieve health goals. Attitude: Respect the centrality of the patient/family as core members of the health care 46 team.

NURSING DIAGNOSES AND INTERVENTIONS Identify 3 nursing diagnoses and 2 nursing interventions that would

NURSING DIAGNOSES AND INTERVENTIONS Identify 3 nursing diagnoses and 2 nursing interventions that would apply to the patient at this time Identify 3 nursing diagnoses and 2 nursing interventions that would apply to the newborn at this time 47

N-CLEX STYLE PRACTICE QUESTION A patient is admitted with abruptio placentae. The nurse should

N-CLEX STYLE PRACTICE QUESTION A patient is admitted with abruptio placentae. The nurse should assess the patient for which of the following signs and symptoms? (Select all that apply) Vaginal bleeding that is concealed or apparent b. Abdominal pain c. Board-like abdomen d. Large placenta e. Incontinence a. 48

N-CLEX STYLE PRACTICE QUESTION A patient is admitted for preterm labor at 33 week’s

N-CLEX STYLE PRACTICE QUESTION A patient is admitted for preterm labor at 33 week’s gestation. The nurse administers betamethasone (Celestone). What is the purpose of giving this drug? To stop the patient’s labor b. To decrease the patient’s pain level c. To promote infant surfactant production d. To prevent a complicated delivery a. 49