RUNNING HEAD: Case Study
Case Study
Sarah Maxwell
Clinical Judgment V
Ohio University
Case Study 2
Introduction
The patient is a female aged 25 and 9 months pregnant when entering the facility. .
Upon looking at her chart her medical diagnosis showed pregnant, use of illicit drugssubstance abuse. Further discovery shows that she completed rehab immediately prior to
her admission. Baby was delivered by C-section due to failure to progress in labor. Baby
born 6lbs 7oz. with no visible health abnormalities. Mother eager to interact with child,
clearly demonstrating love and affection. She has no support system known, no visitors,
and her facial expressions suggest fear and uncertainty. Patient has been recently released
from her incarceration. She was incarcerated months 3-8 of the pregnancy. As a nurse focus
should be towards the patient’s knowledge deficit in order to reduce anxiety, fear and
uncertainty. In addition education should be provided to help with addiction recovery. The
nurse should provide medical care as instructed by the doctor to aid with withdrawal
symptoms, C-section pain, etc.
Pathophysiology
This patient has two main issues going on. One being that she is pregnant, another
being that she is an addict. Pregnancy is caused by a male sperm meeting a female egg or
Ovum inside a woman’s fallopian tube.—this act “fertilizes the egg.” The fertilized egg then
travels down the fallopian tube into the uterus where it implants itself into the wall of the
uterus. (Lu, 2002). Some symptoms of pregnancy are spotting and cramping, a milky white
discharge from the vagina (this should not burn or itch) or breast changes. These breast
changes could include becoming swollen, sore or tingly, feel heavier/fuller, tender to touch,
or darkening of the areola. (WebMD Medical Reference, 2013) Drug abuse or addiction is a
psychological disorder. It has two main factors of environment and genetics. One could be
Case Study 3
strongly encouraged by family members to use drugs or the beliefs and attitudes of one’s
peer group could have an influence. In addition, one may be genetically predispositioned to
to more addicted to substances than someone else due to an inherited trait (Mayo Clinic,
2013). Substance abuse Symptoms of substance abuse include but are not limited to:
Feeling that one must use the drug regularly (daily or several times per day), failing in
attempts to stop using the drug, making certain one has supply of the drug, spending
money on the drug even when one cannot afford it, performing uncharacteristic actions
(like stealing) to obtain the drug, feelings as if one needs the drug to deal with problems,
driving or performing risky behaviors while under the influence of the drug, and lastly;
focusing an increasing amount of time and energy to obtain and sue the drug (Mayo Clinic,
2013).
History
Prior to hospital admission, patient had 2 previous pregnancies. One was a
miscarriage, one an elected abortion. The patient has a history of drug use, anxiety and
depression, seizures, tobacco use, and an unknown STD. Family history includes: spina
bifida, lung cancer, bladder cancer, breast cancer, hypothyroidism, high cholesterol, prediabetes, and bipolar disorder. Her prior surgical history includes: termination of
pregnancy, tonsillectomy/adenoidectomy, and tooth extractions all in 2007. She was
taking pre-natal vitamins and suboxone prior to visit. Patient is allergic to haldol, keflex,
lobster and shellfish. She has no other known illnesses. She does not currently have a
primary physician. During C-section, patient was given general anesthesia and oxygen at
the bedside. Primary C-Section was completed after labor had progressed to stage 2 (4cm).
Case Study 4
Patient is currently receiving a PCA of morphine to curb pain and withdrawal symptoms as
well as suboxine, and torodol. No other medication at this time.
Nursing Physical Assessment:
Mother is doing well post-delivery. Baby has an apgar score of 9 at 1 minute and 9 at
5 minutes. Mother is breastfeeding baby. Her psycho-social assessment reveals a history of
anxiety and depression, speaks English, is unknown/doesn’t comment on her religious
views and history of domestic violence and sexual abuse. The father of baby is listed but
not involved. Patient’s marital status is single. She currently seems unsure of people
entering her room, likes baby sleeping at her side to “keep her safe”. Patient has no social
support network, uses tobacco and alcohol currently, history of heroin and narcotic use.
She has a social services referral and a cord stat drug screening. Her lab results show she is
blood type B+, Rubella immune, HIV negative. Rapid UR drugs clean catch was negative. All
other lab results were within normal limits. Cord Stat Drug screening has not yet been
processed.
The patient is allowed to walk to the bathroom. Her diet is normal with suggestions
to increase calories. On IV drip of 1000 mL. She refused Fundus/Lochia assessment-unable
to perform due to complaint of pain. Patient was educated on why this is done, still refused.
Documented in chart.
Neuro: Patient was alert and oriented x3 with clear speech. Her DTR’s were 1+ in
both legs. She has a minor headache and has seizures of unknown cause, but none within
the “last few years”
Cardio-VASC: Patient has pink warm and dry skin, her peripheral pulses are all
within normal limits and equal. She is presenting with slightly pitting bilateral leg edema.
Case Study 5
She has a negative Homan’s sign and is experiencing epigastric pain of a 6 to 7 that feels
like “an intense ache with a few sharp spurts.”
RESP/GI/REPRO/GU: Patient’s breathing is clear and unlabored at 18 breathes per
minute. Her history includes smoking 1 pack per day. She has no abdominal distention, has
active bowel sounds x4, no hemorrhoids. She was passing flatus post-op. Her breasts are
normal, patient complains of slight pain in nipples. Patient instructed to have baby take
more of the nipple in the mouth to prevent “chewing.” Upon prior examination the fundus
was found firm with light lochia. The perineum showed no signs of edema or hemorrhoids.
The bladder was palpable, with no evidence of a UTI. Urine is yellow and patient is
continent.
Overall: Her basic vitals include: Temperature of 98.2 degrees Fahrenheit, oral;
Blood pressure of 107/70 taken on left upper arm, respirations 18, pulse, 75 strong
normal. Patient’s skin integrity /turgor is good and within normal limits. Her skin color is
slightly pink, normal for race, and exhibits no sign of rash or lesions. Her IV is 18 gauge in
the RAC, and is clean and dry with no redness. Patient incision site is clean with no
drainage.
Related Treatments
Patient is receiving supoxone to help with her addiction, and is receiving no
medication for post-pregnancy. Her treatment was education based and ensuring that she
stayed healthy. Explain what treatments the patient is receiving because of his/her disease
Nursing Care Plan
Nursing Diagnosis and Patient Goal
Case Study 6
This biggest plan that needed to be executed for this patient was education. The
patient had insufficient knowledge and support. This patient’s nursing diagnosis is
deficient knowledge related to infant care/new condition as evidenced by inability to
breast feed baby, homelessness, and patient vocalizing unsureness about how to care for
baby. This new mom needs information on why one shouldn’t co-sleep, SIDS, a lactation
consultant, drug/alcohol use, a support group/social services consult, as well as normal
new mom patient discharge information (Gulanick & Myers, 2011). The goal for this patient
would be that she verbalizes and demonstrates understanding of issues such as cosleeping, baby needs, and knowledge of how to get/is receiving the help she needs to keep
herself and baby safe.
Nursing Intervention
Nursing interventions include providing a quiet atmosphere without interruption to
teach, as well as one of respect, openness, trust and collaboration. In addition, the patient
should be involved in developing the teaching plan-including creating objectives and
goals—the patient knows what they do and don’t know-asking them what they do know is
a great place to start in filling the knowledge voids. Help the patient integrate information
learned and how to apply it to daily life, and teach things that can be integrated into
existing values and beliefs. Use various medias to provide information, and give a copy of
that information to the patient. Order a social services consult for the patient to start in
getting the help she needs (Gulanick & Myers, 2011). Interventions for this patient are
seemingly limitless because the knowledge gap is so large. Starting small so as not to
overwhelm the patient would be beneficial.
Evaluation
Case Study 7
One always wants the patient to improve and get better; however, that is not always
the case. In this instance during the nursing shift the patient did not improve. She
requested that the nurse leave her alone-refusing assessment checks and any
interventions. The patient would not allow for the baby to be placed anywhere but by her
side. This new mom was very frightened—it was suspected that this was due to her recent
incarceration and fear of having her baby taken from her. Unfortunately, it is unknown how
this story ends, one may only hope that mom and baby are both safe and happy.
Recommendations
In the future, it would be beneficial to start the education process with this patient
in a room full of other new mom’s who are also “in her shoes.” Perhaps seeing other mom’s
in the same situation would ease anxiety and fears that are otherwise normal to becoming
a new parent. In addition, social services should have on going contact with the patient to
ensure her and baby’s safety and needs are met.
Case Study 8
References
Gulanick, M., & Myers, J. (2011). Nursing care plans: Diagnoses, interventions, and outcomes
(7th ed.). St. Louis: Elsevier Mosby.
Lu, M. C. (2002). Physiology of pregnancy. Pregnancy health article . New York: The Gale
Group Inc., Macmillan Reference USA.
Mayo Clinic. (2013, July 13). Drug Addiction. Retrieved November 25, 2013, from Mayo
Clinic: http://www.mayoclinic.com/health/drugaddiction/DS00183/DSECTION=symptoms
WebMD Medical Reference. (2013). Pregnancy Symptoms. Retrieved November 25, 2013,
from Health and Pregnancy Guide:
http://www.webmd.com/baby/guide/pregnancy-am-i-pregnant