PERINATAL%20%20UNFOLDING%20CASE%20STUDY

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PERINATAL UNFOLDING CASE STUDY

• Tanya Carmichael, MSN, RNC
• Christina Harkins, MSN, RNC
• Mary Lou Gies, Ed.D, RN
• La Salle University

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INITIAL PRENATAL VISIT

• You are a registered nurse (RN) working in a
  Womens 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. Johnsons medical and obstetrical history
  follows.

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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

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HISTORY

• Social hx
• () tobacco, occasional per patient (pt), lt5
  per/day currently, has smoked off and on for 15
  years
• () cocaine use, states she has not used any
  cocaine/drugs for gt 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 200mg
  BID Albuterol inhaler as needed (prn)
• Family hx Insulin-dependent diabetes mellitus
  (mother) HTN and heart disease (father) lung
  cancer (CA) (maternal grandmother, deceased)

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

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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?

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

• 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

• 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)

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LABORATORY VALUESWhat is the significance of
these lab values?
Determination Patient Result Reference / Normal
Hemoglobin (Hgb) 12.7 g/dL Female 12-16 g/dL
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 Immune
HIV _ _
UDS _ _
Hepatitis B surface antigen _ _
Reference Pagana, K.D, Pagana, T.J. (2003)
Diagnostic Laboratory Test Reference,, 6th Ed.
Mosby, Inc. St. Louis, MO
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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
  patients risk
• to reduce risk of harm to self or others

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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.
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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?

ACOG Committee Opinion, No. 343. (August, 2006).
Psychosocial risk factors Perinatal screening
and intervention. Obstetrics and Gynecology,
108(2), 469-477.
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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?

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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

ACOG Committee Opinion, No. 343. (August, 2006).
Psychosocial risk factors Perinatal screening
and intervention. Obstetrics and Gynecology,
108(2), 469-477.
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RISK FACTORS

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

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RISK FOR PREGNANCY COMPLICATIONS

• Ms Johnsons 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

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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

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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 Cessation
• Provide measures to support quitting

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Signs Symptoms

• 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

• Preeclampsia
• Continuous H/A
• Elevated B/P
• Edema
• Epigastric pain
• Shortness of breath
• Dizziness
• Decreased urinary output
• Visual disturbances (blurred vision or spots)

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• 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.

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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.

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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

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• 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.

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RHOGAM

• After 2 hours of observation with no change in pt
  status, the physician orders administration of
  RhoGAM. 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

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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

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• 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.

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• 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

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

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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 data
• Type screen
• CBC
• Coagulation studies
• Chemistry profile
• Urine analysis including UDS
• Large bore IV and fluids

• QSEN KSA Patient Centered Care
• Attitude Value seeing health care situations
  through patients eyes

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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)

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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

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• Placenta previa ruled out per ultrasound (us). No
  clots noted on u/s. Speculum exam confirms 10 mL
  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

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• 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 97.90F
  Pulse oximeter (pox) on room air 96

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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, 10L O2 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)

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• 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 team functioning

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TO ENSURE MS. JOHNSONS 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

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• 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 99.40F, pox 100 on 10L O2 patient very
  anxious
• FHTs continue to be ominous with repetitive late
  decelerations
• Multidisciplinary team mobilized for stat
  cesarean section

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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 and others
• Attitude Value own role in preventing errors

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TRANSFER TO NICU

• Prior to transfer to the NICU, what priority
  action must the NICU nurse take?

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TRANSFER TO NICU

• The baby must be properly identified via 2 bands
  with mothers name, babys 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

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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?

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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
• QSEN KSA (next 2 slides)

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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

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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 KSA Quality Improvement
• Skill Use tools to make processes of care
  explicit

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PATIENT TRANSFER

• The postpartum nurse does the initial assessment
  and the patients 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
  team.

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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

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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
• Abdominal pain
• Board-like abdomen
• Large placenta
• Incontinence

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N-CLEX STYLE PRACTICE QUESTION

• A patient is admitted for preterm labor at 33
  weeks gestation. The nurse administers
  betamethasone (Celestone). What is the purpose of
  giving this drug?
• To stop the patients labor
• To decrease the patients pain level
• To promote infant surfactant production
• To prevent a complicated delivery