Case StudyJessica Thompson

AndErika Tallman

Demographics T.L. 29 years old G6P5AB1L4 LMP 8/31/10

baby girl 6 lbs 7oz Born 6/1/11 at 1709 39weeks and 1 day gestation. EDD 6/7/11 Bottle feeding (Maternal preference)

OB history Pregnancy #1:was an ectopic pregnancy. Pregnancy #2: resulted in the preterm labor at

36 weeks. Pregnancy #3: resulted in another preterm labor

at 35 weeks. Pregnancy #4: resulted in fetal demise at 32

weeks gestation related to cervical funneling. Pregnancy #5: resulted in a full term baby boy. Pregnancy #6: resulted in a full term

baby girl.

Fatal Pregnancies IUFDOccurred at 32 weeks gestation

when cervical funneling (cone shaped indentation in the cervical os took place) which she birthed.

Ectopic Occurred when the ovum

implanted into a site other than the lining of the uterus.

Incompetent cervix

Painless dilation of the cervix without contractions because of a structural or functional defect of the cervix.

Related risk factors include: multiple gestations and previous preterm births

Education would include the warning signs of preterm labor: lower back pain, pelvic pressure, and changes in vaginal discharge; and the benefits of a cerclage placement.

Cerclage Surgical procedure in which the cervix is

sewn shut primarily in the third month pregnancy (T.L. had this done at 13 weeks, laproscopically), to keep the cervix from prematurely dilating.

Successful in 80-95% of cases. Generally removed in the 37th week of

pregnancy, but can be removed earlier if ROM or true labor contractions occur.

Cervical Cerclage, 2006

videohttp://www.youtube.com/watch?v=630Ax6N6yp0&feature=autoplay&list=PLB5A0A679455613C2&index=1&playnext=2

(elitelaproscopic, 2010)

Ultrasound Criteria for the Diagnosis of Incompetent Cervix

  Normal Pregnancy Cervical incompetence Cervical Length

>3 cm <3 cm

Cervical Width

<2 cmin second trimester.

>2 cmin second trimester.

Cervical Canal Width

<8 mm >8 mm

Cervical funneling

None or< 25%

25-50% or> 50%

Bulging of Membranes

into cervical canal

None Present fetal parts

J. Ludmir

PP Bilateral tubal ligation“having your tubes tied”

Permanent, irreversible form of birth control that is over 99% effective.

Procedure includes making an incision just above the navel and using laparoscopic tools to snip the fallopian tubes and cauterize them, pain is relieved through the use of anesthesia.

Can be done in an outpatient setting.

Lab workTest Normal PT result analysis

Blood workType &Rh

Maternal :O+Baby: B+

Risk for ABO incompatibility, may cause newborn jaundice R/T hemolysis; hyperbilirumia. Rh is not an issue.

Hemoglobin & hematocrit

11mg/dL & 33% in pregnancy

11.5mg/dL & 34%

No issues

VDRL/ RPR Negative No risk to fetus

Rubella Immune No risk to fetus

GC-C Negative No risk to fetus

OtherGBS

negative positive Treatment given: penicillin X 2

Pregnancy Related tests

Test Normal PT Result Analysis

Pap smear Normal No STIs or cancer

1 hr Glucose tolerance

<130mg/dL 129mg/dL No GDM

Biophysical Profile

8-10 9 Fetal wellbeing

NST 2 accelerations of at least 15 bpm for 15 seconds within 20 mins

Reactive Fetal wellbeing

Labor and Delivery

T.L’s labor was induced when her Cerclage was removed on 5/31/11 and amniotomy at 1915, with an epidural, LR with pitocin, and a foley bulb, her labor took 22 hrs, with a 9 minute 2nd stage and a 3 minute 3rd stage, with 250mL blood loss and a 2nd degree laceration.

Because T.L. was gbs+, she was also taking penicillin via a IV piggyback.

Labor and Delivery contd.

FHR remained in the 130s bpm with moderate variability, monitored consistently with an external transducer.

The baby girl scored a 9 out of 10 on the APGAR scale at 1 and 5 minutes of age.

PP assessment

Vitals0900: BP 124/76, HR 70, R 14, T 36.7

Pain 0/101400: BP 122/74, HR 66, R 14, T 36.5

Pain 4/10- medicated with vicodin and motrin

BUBBLE-HEB was within normal limits

Newborn assessmentVitals0800: HR 140, R 45, T 36.5

Pain 0/101500: HR 150, R 45, T 36.5

Pain 0/10

Reflexes present Skin and mucosa

within normal limits

fontanels soft and level

Symmetrical movements

Voiding adequatelt

Newborn Feedings T.L.’s choice to not breastfeed, the baby

girl now gets her nutrition through Similac advanced formula every 3-4 hours.

Feedings1. 0530- 22cc2. 0900- 20cc3. 1130-5cc4. 1300-5cc5. 1530- 5cc

PP medications Vicodin: Opiod analgesic, generalized CNS

depression for moderate pain.1 tab (5mg) q4hr PO : not to exceed 4000mg/day.

Prenatal vitamin: with iron supplement. 1 tab/day

Motrin: nonopiod analgesic/nonsteroidal anti-inflammatory/ antipyretic: inhibits prostaglandin synthesis.

Prn: 600 mg q6hr PO Americaine ointment: anesthetic, local pain relief

Prn applied topically Tucks(witch hazel) pads: analgesic, local pain relief

R/T hemorrhoids. Prn applied topically

Nursing Diagnosis #1Risk for infection

AEB… inadequate primary defenses, invasive procedures and environmental exposure.

•Normal labor trauma•Tubal procedure•Not as active

•Hospital environment

Goal: Be free of purulent drainage or secretions, and other signs of infections

throughout the healing process.

education

Evaluation: At this time the patient was free of infection and expressed understanding of

education.

Intervention 1

Monitor and educate on the following for signs of infection: ■Redness, swelling, increased pain, or purulent drainage at incisions, injured sites, exit sites of tubes, drains, or catheters Any suspicious drainage should be cultured; antibiotic therapy is determined by pathogens identified at culture.■Elevated temperature Fever of up to 38° C (100.4° F) for 48 hours after surgery is related to surgical stress; after 48 hours, fever above 37.7° C (99.8° F) suggests infection; fever spikes that occur and subside are indicative of wound infection; very high fever accompanied by sweating and chills may indicate septicemia.■Color of respiratory secretions Yellow or yellow-green sputum is indicative of respiratory infection.■Appearance of urine Cloudy, foul-smelling urine with visible sediment is indicative of urinary tract or bladder infection.

Check and chart vitals

every shift for comparison.

Give written information

about signs of infection

Physician should be

notified of any signs or

symptoms of infection

Intervention 2

Teach patient or caregiver to wash hands often, especially after toileting, before meals, and before and after administering self-care. Patients and caregivers can spread infection from one part of the body to another, as well as pick up surface pathogens; hand washing reduces these risks.

Wash hands before and after client

care

Note patient understanding of education

given

Note patient compliance of

proper perineal cleanser and

hygiene

Nursing Diagnosis #2Risk for disturbed body image

AEB… situation, focus on past appearance, change in social

involvement•Multiple pregnancies

•40 lbs weight gain, wishes to lose all•Newborn to care for

Goal: improve and maintain self-esteem through the first post-partal year

illustrated verbally.

psychological

Evaluation: At this time the patient is unsatisfied with current body weight

and BMI illustrated by verbal negativity.

Intervention 1

Note patient’s behavior regarding actual or perceived changed body part or function. There is a broad range of behaviors associated with body image disturbance, ranging from totally ignoring the altered structure or function to preoccupation with it.

Promote patient to communicate concerns with

family and healthcare provider

Allow patient to initiate

conversation about subject of

her body

Give information

about realistic weight loss

goals

Intervention 2

Assist patient in incorporating actual changes into ADLs, social life, interpersonal relationships, and occupational activities. Opportunities for positive feedback and success in social situations may hasten adaptation

Be positive in conversations

Discuss healthy

nutritional and physical

activity options

Give information pertaining to

breastfeeding and the extra calories burned along with

the importance for the newborn

Nursing Diagnosis #3

Newborn: imbalanced nutrition: less than body requirements

AEB… lack of interest in food•Decreased intake

Goal: maintain and increase weight, be free of signs of malnutrition daily

and throughout early childhood

nutrition

Evaluation: At this time the patient is not having adequate intake

Intervention 1

Monitor laboratory values that indicate nutritional well-being/deterioration: Serum albumin: This indicates degree of protein depletion (3.8 to 4.5 g/dl is normal).

Transferrin: This is important for iron transfer and typically decreases as serum protein decreases.

RBC and WBC counts: These are usually decreased in malnutrition, indicating anemia and decreased resistance to infection.

Serum electrolyte values: Potassium is typically increased and sodium is typically decreased in malnutrition

Draw labs once daily for

evaluation

Document any values off baseline/norm

and notify physician

Evaluate any supplemental options if lab

values are abnormal

Intervention 2Suggest ways to assist patient with meals as needed. This educates and encourages adequate feedings. Ensure a pleasant environment, to improve comfort levels both maternally and for the newborn. facilitate proper positioning; nipple placement and a proper latch facilitates feeding and provide good oral hygiene to reduce risk of aspiration

Encourage frequent and

possible smaller meals

Monitor weight gain

and I&O

Make sure formula is at a comfortable temperature, and nipple is appropriate

Nursing Diagnosis #4Disturbed sleep pattern

AEB… situation and environmental changes

Previously prescribed sleep aide •Hospitalization

•Newborn at home•4th child living in household

Goal: Verbalize increased sense of well-being and adequately rested within discharge and by the first follow-up

doctors appointment

physiological

Evaluation: At this time the patient is not getting adequate rest, illustrated

verbally.

Intervention 1

Identify factors that may facilitate or interfere with normal patterns. Knowledge of its role in health/wellness and the wide variation among individuals may allay anxiety, thereby promoting rest and sleep.

Provide comfort

measures that assist in

relaxation

Evaluate and educate on help from family and

friends once at home

Allow mother alone time to

rest when she chooses

Intervention 2

Instruct patient to follow as consistent a daily schedule for retiring and arising as possible. This promotes regulation of the circadian rhythm, and reduces the energy required for adaptation to changes.

Discuss sleep patterns

effective with previous

pregnancies

Provide information on the importance

of sleep and various tricks to

allow for adequate sleep.

Monitor current sleep pattern and

consult with physician for

pharmacological measures if

needed.

References (2006). In Cervical Cerclage. Retrieved Jun.

7, 2011, from http://www.americanpregnancy.org/pregnancycomplications/cervicalcerclage.html

Body Image Disturbance; Weight training may be effective for body- imaged-disturbed college women :[1]. (2004, November). Obesity, Fitness & Wellness Week,141. Retrieved June 13, 2011, from ProQuest Nursing & Allied Health Source. (Document ID: 738930181).

Doenges, M, & M. Moorhouse, & A. Murr. (2010). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span. Philidelphia, PA: F.A. Davis.

elitelaproscopic,. (2010, Mar. 3 ). In Laproscopic Cervioc-Isthmic Cerclage. Retrieved Jun. 7, 2011, from http://www.youtube.com/watch?v=630Ax6N6yp0&feature=autoplay&list=PLB5A0A679455613C2&index=1&playnext=2

Fogelson, N.. (2010, Feb. 27 ). In Cerclage How-To . Retrieved Jun. 7, 2011, from http://academicobgyn.com/2010/02/27/academic-obgyn-cases-abdominal-cerclage-how-to

Gulanik, Myers, Klopp, Galanes,. (2009). In EHS: Nursing Care Plans: Diagnosis and Intervention. Retrieved Jun. 8, 2011, from http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor

Harmat, L., Takács, J., & Bódizs, R.. (2008). Music improves sleep quality in students. Journal of Advanced Nursing, 62(3), 327. Retrieved June 13, 2011, from ProQuest Nursing & Allied Health Source. (Document ID: 1468397021).

Louey, M.. (2006). Formula Feeding: Fluid Evidence Summaries. Retrieved June 13, 2011, from Evidence-Based Resources from the Joanna Briggs Institute. (Document ID: 1445804761).

Ludmir, J. In Ultrasound Criteria for the Diagnosis of Incompetent Cervix. Retrieved Jun. 8, 2011, from http://www.fetalultrasound.com/online/text/33-039.htm

Stulberg JJ, Delaney CP, Neuhauser DV, Aron DCm FU P, Koroukian SM. Adherence to Surgical Care Improvement Project Measures and the association with postoperative infections. JAMA. 2010; 303(24): 2479-2485.