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answer all questions in the Suzanne M. case study and in the lab report ensuring that all provided tables are filled. Ensure that all questions are accurate and follow the provided rubric suzanne_case_study_rubric_3.docx sba2r3_report__2.docx suzanne_case_study_1.docx Unformatted Attachment Preview NUR 115 Suzanne Case Study Rubric Name: Criteria 1 Determine patient risk factors for preeclampsia and map initial status. 2 Evaluate change in patient status and implications for a developing complication. 3 What is the CMQCC recommended health team response for this patient? 4 Rationale for order to evaluate lung sounds 5 Map change in patient status and implications for a developing complication. 6 What is the CMQCC recommended health team response for this patient? 7 SBA2R3 Report 8 Staff notifications and rationales. 9 Discuss appropriateness of the orders given. 10 Adverse effects of Magnesium Sulfate therapy that must be reported. 11 Problems of the 32-week preterm newborn. 12 Appropriate postpartum bed assignment 13 Maternal discharge teaching. 14 Criteria for discharge from NICU Care Total Points: Notes Points Yours 10 10 5 5 10 10 15 5 5 5 5 5 5 5 100 SBA2R3 Report SBA2R3 Elements Notes SITUATION: PRIMARY PROBLEM Origin Course Current Status BACKGROUND: RELEVANT history ASSESSMENT/ANALYSIS: Current Vital Signs: RELEVANT Physical Assessments: Mental Status: RELEVANT Labs/Diagnostics: TRENDS of Abnormal Findings: Unstable, Stable, Worsening, Improving Patient Response to Interventions: RECOMMENDATIONS/ RATIONALES: Changes in treatment plan MD to see this patient now ICU/CCU transfer New Labs/Diagnostics New Medications Specialty Consultation RESPONSE Questions Discussion Agreement on action plan As Dr. Allen is this patient’s admitting physician, and he has been updated on her status throughout the night, you do not need to provide patient background information. MOUNT WACHUSETT COMMUNITY COLLEGE DEPARTMENT OF NURSING NUR 115 PREECLAMPSIA CASE STUDY SUMMER, 2020 YOUR TEXT PAGES 172-178 WILL BE HELPFUL FOR THIS ASSIGNMENT. STUDENT______________________________________________ SITUATION: January 11th, 2019 19:00 Suzanne M. has come to the Labor and Delivery unit at a Level III (NICU) hospital with an admitting diagnosis of “Rule out Preeclampsia.” Dr. Allen, her obstetrician, has written these orders: Assessments: Fetal non-stress test for each twin, then continuous electronic fetal monitoring. Vital Signs: Blood pressure on admission and every 15 minutes in semi-Fowler’s position Respiratory assessment on admission, hourly and as needed Continuous pulse oximetry Pre-eclampsia assessments hourly and as needed: Level of consciousness Headache Visual changes Abdominal or Chest Pain Deep tendon reflexes and clonus Activity: Bed rest with bathroom privileges. Labs: Clot and hold for possible future type and cross match. CBC Liver enzymes (AST, ALT) Serum creatinine Urinalysis Phone report to Dr. Allen as soon as lab results are available. Background: Suzanne is a G3P0 who is pregnant again through in vitro fertilization (IVF) with twins. Now at 32 weeks, this pregnancy has gone well so far. She has no chronic health conditions. She is CEO of the tech company she started, and the business is thriving. 1 Suzanne read something on the web about preeclampsia last week. She is very interested in this topic because her own mother, Maris, had preeclampsia when she was pregnant with Suzanne (Maris’s first child) and again during her fifth and final pregnancy. Suzanne herself did not experience preeclampsia in her first two pregnancies, both of which ended spontaneously early in the second trimester. When Suzanne started feeling strange today, she remembered the article and called for an urgent appointment with her obstetrician. In the office, Dr. Allen listens attentively to Suzanne’s vague complaints, and her concern that she might have preeclampsia. He notes that Suzanne does not have any peripheral edema, but her blood pressure is mildly elevated at 138/86, and a urine dip shows a trace of protein. Dr. Allen’s general attitude is that pregnant women are often unduly influenced by alarmist information they read on the web, but he also believes he should act on patient concerns, no matter how groundless they may seem. Although nothing he had heard or seen during the appointment concerned him, he sends Suzanne to the L&D unit for labs, blood pressure monitoring, and a non-stress test on the twins, just to be thorough. 1. a. (5 pts) According to the list of Risk Factors for Preeclampsia found on page 174 of your text, what risk factors are present in Suzanne M.’s history and current situation? b. (5 pts) Map current assessments onto the CMQCC Preeclampsia Early Recognition Toolkit Table. Assessment Systolic BP 138 Diastolic BP 86 Proteinuria: Trace Normal Worrisome Severe ASSESSMENTS: The nurse orients Suzanne to the labor room, explains procedures, and asks her to change into a hospital gown to facilitate the NST for the two babies. She instructs Suzanne on collecting the urine specimen for urinalysis, initiates the NSTs, begins ordered assessments, and facilitates lab specimen collection. Suzanne is alert and oriented, giving directions over the phone to her administrative assistant for managing aspects of her business while she (Suzanne) is in the hospital. Both Suzanne and Dr. Allen believe this will be a short stay to confirm the absence of preeclampsia. January 11th, 20:20 – lab results are available. 2 2. (10 pts) Map lab and assessment findings to the CMQCC Preeclampsia Early Recognition Toolkit Table. Assessments Vital Signs Systolic Blood Pressures Range Diastolic Blood Pressure Range Respiratory Assessments Pulse Oximetry Preeclampsia Assessments Level of Consciousness Headache, N/V Visual Changes (Blurred) Abdominal/Chest Pain DTR’s/Clonus Labs Platelets Liver Enzymes (ALT/AST) Serum Creatinine Urinalysis Non-Stress Test/Fetal Monitoring Fetus A Fetus B Findings/Results Normal Worrisome Severe 140 to 156 80 to 88 14 to 22; no SOB ≥ 95\% on RA Alert and Oriented Denies Denies Denies 2+, no clonus N/A* 150k 53/67 0.9 +1 protein Reactive, Category I Reactive, Category I * Considered in the CMQCC Protocol only if the patient is on magnesium sulfate IV therapy. 3. (5 pts) What is the CMQCC recommended health team response for this clinical picture? NEW ORDERS January 11th 21:00 After receiving report from the nurse, Dr. Allen orders over-night observation, continuing all assessments, extending blood pressure assessments to hourly instead of every 15 minutes and allowing patient to assume a side-lying position for sleeping comfort. Labs are to be repeated at 06:00 and results called to the physician as soon as available. CONTINUING ASSESSMENTS During the night, Suzanne becomes nauseous and vomits several times. At 02:00 the nurse reports this to the physician and requests an order for Zofran (ondansetron). The physician complies, adding orders for IV 3 Lactated Ringers at 125 mL/hour, NPO status, and a Foley catheter with careful calculation of fluid intake and output. 4. (5 pts) The physician also adds lung sounds to the respiratory assessment. Why is this necessary? Over the night shift, Suzanne vomits a total of 1700mL. She declines the Zofran for the nausea and does not sleep well. Ordered labs are drawn at 06:00. Between 06:00 and 07:30, Suzanne becomes alternately confused/agitated and somnolent. At 07:20, the nurse enters the room to find her sitting up on the edge of the bed, Johnny removed, trying to get up to go to the bathroom because she has to pee. The nurse helps her get back into her Johnny and back to bed, explaining that the presence of the Foley means she doesn’t have to go to the bathroom to pee. Suzanne tells the nurse, “I’m really out of it, aren’t I.” 5. (10 pts) Map the new assessments and lab results to the CMQCC Preeclampsia Early Recognition Toolkit Table. Assessments Vital Signs Systolic Blood Pressures Range Diastolic Blood Pressure Range Respiratory Assessments Pulse Oximetry Preeclampsia Assessments Level of Consciousness Headache, N/V Visual Changes (Blurred) Abdominal/Chest Pain DTR’s/Clonus Fluid Intake & Output Urine Output Labs Platelets Liver Enzymes (ALT/AST) Serum Creatinine Non-Stress Test/Fetal Monitoring Fetus A Fetus B Findings/Results Normal Worrisome Severe 158-164 98-108 14-18, no SOB, clear ≥ 95\% Confused, agitated Nausea & Vomiting Denies Denies 3+, no clonus. 625/1825 125 over 5 hours N/A* N/A** 96 73/116 1.0 Category I Category II *Not considered under the CMQCC Protocol unless the patient is on magnesium sulfate IV therapy. Many practitioners consider increasing DTR’s, especially with clonus, to be indicative of increased CNS tone and predictive for seizure. ** Not considered under the CMQCC Protocol, however essential for the patient who is on IV fluids, especially when the patient is at risk for fluid imbalance due to vomiting, or on magnesium sulfate IV therapy. 4 6. (5 pts) What is the CMQCC recommended health team response for this clinical picture? 7. (15 pts) Prepare an SBA2R3 report for this patient’s change of status. NEW ORDERS January 12th 07:40 Dr. Allen receives the nurse’s SBA2R3 report, which includes a current blood pressure of 180/110 and continued agitation/confusion alternating with somnolence. Dr. Allen states that he will arrive in about 30 minutes and gives these telephone orders: Face-to-face evaluation by senior obstetric resident physician now. Magnesium Sulfate 4 grams in 100 mL NS IV over 20 minutes followed by Magnesium Sulfate 2 grams/hour. Labetalol 20 mg IVP over 2 minutes. If not effective in bringing BP below 160/105-110, Then escalate doses (40 mg, then 80 mg) IVP every 20 minutes. Total not to exceed 220 mg in 24 hours. BP Goal: 140-150/90-100. Dosing and response to be supervised by senior obstetric resident physician. Blood type and cross match for 2 units packed red blood cells. Notify appropriate personnel of likely C-Section birth of twins at 32 weeks gestation. 8. (5 pts) Who are the “appropriate personnel” who should be notified about this patient’s change of status and the potential track her treatment may soon be following? Why? (Use your clinical imagination!) Who should be notified? Why? 5 9. (5 pts) Are these orders appropriate, considering CMQCC recommendations and the patient’s current status? Were some recommended orders omitted? Why do you think that might be? Support your answer with evidence- based rationales. 10. (5 pts) From your text book, (Bottom of page 177 to page 178 - “Care of the Woman on Magnesium Sulfate”) list 7 abnormal maternal assessments that must be reported to the obstetrician. January 12th 08:20 By the time Dr. Allen arrives, the obstetric resident physician has been in to evaluate the patient, the magnesium sulfate bolus has been delivered, and magnesium is now infusing at a rate of 2 grams/hour. All assessments related to preeclampsia and magnesium sulfate therapy have been normal, except for Suzanne’s cognitive status. Her blood pressure is within the target range (140-160/90-100) and she is hemodynamically stable. The patient’s husband Thom has arrived and is acting as health care proxy for Suzanne, who is not fully capable of participating in decisions. Considering Suzanne’s cognitive status, and that both fetuses are now experiencing fetal heart rate changes that define Category II, the difficult decision is made collaboratively to proceed with C-section birth of the babies at 32 weeks. The plan moves forward quickly, and both babies are now stable and in the care of the NICU teams. 11. (5 pts) Anticipate the five main health concerns/needs of infants born at 32 weeks gestation (moderately preterm). List and briefly describe. https://www.verywellfamily.com/what-is-a-moderately-preterm-baby-2748626 While Suzanne is recovering in the Post Anesthesia Care Unit (PACU), there is an inter-professional discussion as to whether she should be transferred to the Postpartum Unit, to the Intensive Care Unit (ICU), or back to the Labor & Delivery Unit. Advantages and disadvantages of each location are listed here. Care Unit Postpartum Unit Advantages More homey environment, less stimulating (quieter) than L&D or ICU. Closest proximity to the NICU for visiting babies. Labor & Delivery Unit Nursing expertise with Disadvantages Lack of nursing expertise with magnesium sulfate therapy management Preeclampsia, Eclampsia, HELLP Syndrome Higher ratio of patients to nursing staff Not enough nursing staff to take Suzanne to the NICU to visit, or to care for the babies were they to come visit mom here. Unpredictable ratio of patients to nursing staff 6 Intensive Care Unit magnesium sulfate therapy management Preeclampsia, Eclampsia, HELLP Syndrome Closer proximity to the NICU for visiting babies. 1:1 nursing care around the clock is the standard. Nursing expertise with addressing systems dysfunctions associated with Preeclampsia, Eclampsia, and HELLP, and complications of magnesium sulfate therapy. Staff sufficient in number and knowledge/skill to manage any complication that may arise. High census of laboring mothers may mean less attention to Suzanne with increased risk of complications. Noisy, fast paced environment with little privacy. Farthest from the NICU for visiting. Protocols would prohibit mother from leaving to visit NICU. Babies require intensive care too and cannot come to ICU to visit with mother. If recovery goes well, Suzanne will not be sick enough to require ICU care for very long. 12. (5 pts) Considering that Suzanne will be on Magnesium Sulfate for another 24 hours, that her cognitive status is still abnormal, and that the risks of Eclampsia and HELLP Syndrome do not end with the birth of the babies, which Unit would be the best placement for Suzanne and Why. January 16th 15:00 Suzanne’s recovery has gone well and she is ready for discharge on postop day #4. She will be staying at the hospital in a “boarder room” so she can be close to her babies, who are expected to be ready for discharge in about 3 weeks. Her discharge teaching form is available in this folder. 13. (5 pts) Suzanne looks over the discharge teaching sheet and asks, “What does this mean? I thought I was out of the woods at this point, but I could get sick again?” Construct a thoughtful response that will help Suzanne to comply with self-monitoring but not frighten her. 14. (5 pts) List and briefly describe the milestones that a preterm infant must achieve before discharge home. https://www.verywellfamily.com/milestones-a-nicu-baby-must-reach-before-discharge-2748598 7 ... Purchase answer to see full attachment