Abruptio Placentae with Preterm Labor and Delivery UNFOLDING Clinical Reasoning case Study NEWEST 2022.

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Abruptio Placentae with Preterm Labor and Delivery UNFOLDING Reasoning Michelle Moore, 38 years old Primary Concept Perfusion Interrelated Concepts (In order of emphasis) 1. Reproduction 2. Ox... ygenation 3. Pain 4. Clinical Judgment 5. Patient Education 6. Communication 7. Collaboration © 2019 Keith Rischer/www.KeithRN.com UNFOLDING Reasoning Case Study: ANSWER KEY Abruptio Placentae with Preterm Labor and Delivery History of Present Problem: Michelle Moore is a 38-year-old who is 29 weeks pregnant. She began prenatal care at 18 weeks gestation because she was waiting to become insured. She is currently in the Labor and Delivery Unit of the hospital following a call to her primary care provider. She reported that she had a sudden onset of constant severe uterine pain and began to notice that she had vaginal bleeding that bright red, soaked a maxi pad and then began soaking through her underwear. Her baby has not been moving as actively as normal since the pain and bleeding started. Personal/Social History: Michelle works at a fast-food restaurant, standing on her feet for long hours. She usually works in the evenings and weekends. She is estranged from the father of the baby. Michelle’s father is able to help her with childcare once or twice a week. Michelle denies substance use including alcohol during her pregnancy. Michelle smokes 10 cigarettes daily, and says that she has decreased usage, but the stress of the pregnancy and having little support makes it difficult for her to quit. Michelle reports that she usually eats at work to save money, and most meals consist of fried foods and diet sodas. Michelle has a small apartment, but says she often has difficulty paying the rent on time, since child care is so expensive. She has a six-year old son who was born prematurely at 35 weeks. Michelle was diagnosed with a partial abruption during that delivery. Past Medical History (PMH): Home Meds: Pharm. Classification: Expected Outcome:  Gravida 4, Para 1 with a partial abruption at 35 weeks  Two spontaneous abortions in the first trimester  Menses began at age 12, are usually 29 days apart, lasting for 4-5 days, with moderate-to-light flow.  Successfully breast fed her first child for 11 months.  Vaccinations are up to date.  Michelle is biracial: African American and Asian, and she was tested for sickle cell trait. Lab results reveal Michelle is a carrier of the trait. It is unknown if the father of the baby is also a carrier. 1.Prenatal vitamin 1 tab PO daily 2.Acetaminophen 650 mg PO PRN every 6 hours for infrequent, mild headaches 1. Multivitamin 2. Analgesic 1. Pt will maintain adequate iron and vitamin levels during pregnancy 2. Pt will be free of mild headaches What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT Data from Present Problem: Clinical Significance:  38 yrs old  29 weeks pregnant  Present at PCP direction  Severe uterine pain  Bright red vaginal bleeding  Reduced fetal movement since onset of bleeding and pain  Maturity of handling situation  If situation escalates to delivery, will need to take required steps and mobilize appropriate personnel  Adds immediate validity to situation – facilitates communication  Uterine pain with bright red blood is an indication of possible placental abruption  Reduction of fetal movement is indication of possible fetal distress RELEVANT Data from Social History: Clinical Significance:  Works long and night/weekend hours  Baby’s father not involved; her father has limited time to help  Smokes  Stress of work combined with poor nutrition, and smoking can negatively impact fetal development  Support network is insufficient  Inability to meet financial needs can add psychosocial stress  Eats at work  Difficulty paying rent/expensive childcare  Hx of premature birth  Hx of placental abruption  Increased stress hormones can negatively impact pregnancy  Hx increases odds of both premature and placental abruption occurring in subsequent pregnancies Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 98.5 F/ 36.9 C (oral) Provoking/Palliative: Constant, nothing makes it worse or better P: 122 (regular) Quality: “knife-like” R: 24 (regular) Region/Radiation: abdominal BP: 132/64 MAP: 87 Severity: 9/10 O2 sat: 96% room air Timing: constant What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance:  Slightly pyretic  Tachycardic  Tachypnic  Increased BP  O2Sat  Pain 9/10, severe and constant/no relief  Main vital signs all support patient report of pain  Elevated HR could be due to hemorrhage  Constant pain and severity levels need to be immediately addressed  O2 level indicates good oxygenation which is the first step to make sure baby is as well Current Assessment: GENERAL APPEARANCE: 5’ 4” (162.5 cm) tall and weighs 165 pounds (75 kg), including 25 pounds (11.4 kg) she gained during this pregnancy. Appears uncomfortable, groaning and holding abdomen RESP: Breath sounds clear with equal aeration bilaterally, labored respiratory effort CARDIAC: Pale, cool/dry, no edema, 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) FETAL Monitoring: Electronic Fetal Monitoring: Fetal heart rate 150, minimum variability trending towards absent variability around the baseline, late decelerations, no accelerations noted. Contractions are frequent: every 1-2 minutes; uterus is board-like upon palpation [Show More]

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