Student:
Jessica
Anderson
Azusa Pacific University
GNRS 575
MATERNAL, NEWBORN, WOMEN’S HEALTH CARE MAP
Admission
Primary Nurse:
Date:
Letty
9/17/13
Date of Care:
9/19/13
HISTORICAL INFORMATION
Patient’s
Initials: D.L.
Age: 29
years
BP range(on
prentatal records)
ALLERGIES:
Room
Number: 330
Sex: Female
BP’s were never
under 150/99
No Known Allergies
Admitting Diagnosis:
Unit:
Ht
4’9”
Postpartum
Wt
BMI
Lbs 161lbs.
kg 73.029 kg
33.66 kg/m^2
Pregnant (37 weeks and 3 days), Vaginal Bleeding
History Of Present Illness:
Chronological account of patient’s current
illness with pertinent +’s and –“s included
and correct medical terminology used.
D.L. came into the clinic for an appointment and had
minimal bleeding. After she left the clinic and went
home she noticed an increase in the amount of
bleeding. The patient noted that she had filled two
pads within an hour. An hour later she filled three
more pads within an hour. She decided to come into
the hospital and was admitted. The patient had
pregnancy induced hypertension with a history of her
BP’s never being lower than 150/99. When admitted
on 9/17/13 the patient was 37 weeks and 3 days.
There is good fetal movement. The patient’s water
was broken at 0239 on 9/18/13. The patient was
only 3cm dilated and 60% effaced. Due to the heavy
amount of bleeding, the patient was said to have an
abruption of the placenta and that the patient needed
a C-section.
Past Medical History:
Major illness, surgeries, traumas, known
allergies.
The patient had a thyroidectomy in 2008. D.L. has
developed gestational diabetes during this pregnancy,
which is her first pregnancy.
Social/Family History:
Family medical and mental health history,
composition of family, living conditions,
safety issues, habits, etc.
D.L. had her family at the bedside. Her husband was
present and very attentive and supportive. Her
mother and other relatives were present and at her
bedside. The patient is a scheduling counselor for a
firm and her husband works in accounting. They
have a home and have already started preparing for
the baby. The patient’s father has a history of
diabetes. The patient does not smoke or do drugs.
She drinks occasionally when she is not pregnant.
OB History:
Past pregnancies, obstetrical complications
in previous or current pregnancies, etc.
G1/T1/P0/A0/L0 This is the patient’s first pregnancy.
She has pregnancy-induced hypertension with this
pregnancy.
PATHOPHYSIOLOGY/PHYSIOLOGY
Include a brief description of your patient’s disease process. This should be told in a narrative
“story” form.
If your patient has had an essentially “normal” process you must highlight the normal physiology
that occurs in this type of patient (i.e. normal postpartum physiology for a postpartum patient).
For a patient who has a pathophysiologic process occurring, include the pathophysiological
changes that occur in the current diagnosis(es) and explain how the concurrent diagnoses affect
the priority diagnoses.
For all patients: (1) Explain usual/expected treatment (2) Highlight what diagnostic tests,
treatments, or teaching are currently being done for your patient.
Pregnancy-induced hypertension (PIH) is high blood pressure that occurs after the first
half of the pregnancy (or 20th week) for the first time and when the blood pressure returns to
normal within 12 weeks of delivery. High blood pressure is having a blood pressure 140/90 or
over for an extended period of time. It is pregnancy-induced hypertension and not preeclampsia
when there are no signs of proteinuria. This patient was a first time mom and sometimes first
time moms can be at a higher risk. PIH is a concern because this means that there is an
increased resistance in the blood vessels and this can cause a hindrance in the blood flow to
important organs, one of them being the placenta. Another concern with PIH is that it can cause
placental abruption, in which the placenta tears away from the uterus. This causes
hemorrhaging and major complications for the baby because the baby relies on the placenta for
survival. This patient was able to have a C-section when her placenta abrupted because the
baby was viable at 37 weeks and 4 days (Davidson, London, & Ladewig, 2012).
Expected tests for a woman with pregnancy-induced hypertension (PIH) includes regular
blood pressure monitoring, urine testing, liver and kidney tests and frequent weight
measurements. Treatment for PIH can include bedrest, hospitalization, magnesium sulfate, fetal
monitoring, continued laboratory testing of urine and blood, delivery of the baby when possible
(Davidson, London, & Ladewig, 2012).
This patient had frequent blood pressure readings and the BP’s never went under 150/99
during her pregnancy. While she was in the hospital she was receiving magnesium sulfate
through an IV to help with her hypertension and prevent any seizures that might occur. She was
kept on the IV for 24 hours after the delivery. The baby was delivered via cesarean when the
placenta abrupted.
DIAGNOSTICS/LABORATORY/TREATMENT DATA
List all labs
Prenatal:
Blood type
Rh factor
HIV 1+2
HbsAg (HepB)
GBS
Rubella IGG
Current:
WBC
(103cells/mm3)
Normal value
range for your
patient’s age
(9/4/13)
ABO
- /+
Non-reactive
Non-reactive
Negative
Immune
Most Recent
(Date)
Previous
Recent
(Date)
O
+
Non-reactive
Non-reactive
Negative
Immune
(9/17/13)
Before Birth
500012,000/microliter
130,000-400,000
9,000/microliter
Interpretation of abnormal
labs (tie into pathophysiology
of illness)
Not
available
Not
available
Platelets
148,000
Not
available
(mm3)
Hemoglobin
12-16 g/dL
12.1 g/dL
Not
available
(g/dL)
Hematocrit
38%-47%
38.6%
Not
available
(%)
*Values for normal found in the table (Davidson, London, & Ladewig, 2012, p. 327).
Imaging:
Ultrasound at 20 weeks
Results:
Showed girl with an enlarged clitoris
All Ordered Medical
Treatments and
Nursing Activities):
C-section
Results and Rationale:
Magnesium Sulfate
Monitoring Blood
pressure post C-section
The patient’s placenta had abrupted and the patient was only 3cm dilated
and 60% effaced. The C-section went smoothly and delivered a healthy
baby boy. In cases of moderate to severe placental separation, a cesarean
birth is done (Davidson, London, & Ladewig, 2012, p. 677).
The patient was placed on magnesium sulfate to prevent seizures and
help with the patient’s blood pressure. A woman who has received
magnesium sulfate antepartally will continue to receive the infusion for
about 24 hours postpartum (Davidson, London, & Ladewig, 2012, p. 469).
The patient’s blood pressure is 127/75. If preeclampsia does not develop
and blood pressure returns to normal by 12 weeks postpartum, the
diagnosis of gestational hypertension may be assigned (Davidson, London,
& Ladewig, 2012).
IV Solutions/Additives:
Maintenance Rate:
50mL/hr
Magnesium Sulfate
50mL/hr
Lactated Ringer
Nursing Responsibilities:
Monitor the IV lines and the
site.
Monitor the patient for any
seizures.
Monitor the IV lines and the IV
site.
NURSING PROCESS APPLICATION
Note: You may NOT use “PAIN” as a diagnosis for your labor or PP patients more than once in the
semester!
Problem/ Nursing Dx (Physical)
1.
2.
3.
4.
Impaired skin integrity related to a cut in the skin as evidenced
by an incision in the patient’s abdomen and staples holding the
incision together.
Goal: The patient’s incision will not become infected or show
dishescences during her stay at the hospital.
Interventions:
Rationales:
Assess the general condition of the skin.
1.
“Assessment provides a basis for
interventions. Healthy skin varies among
individuals but should have good turgor, feel
warm and dry to the touch, be free of
impairment, and have quick capillary refill”
(Gulanick & Myers, 2011, p.179).
Monitor site of skin impairment at least once a 2. “Systematic inspection can identify impending
day for color changes, redness, swelling,
problems early” (Ackley & Ladwig, 2011, p.
warmth, pain or other signs of infection.
770).
Do not position the client on site of skin
3.
“Continue to turn/reposition the individual
impairment and turn and position the client
regardless of the support surface used (Ackley
every 2 hours to prevent further skin damage.
& Ladwig, 2011, p. 770).
Encourage adequate nutrition and hydration. 4.
“Optimizing nutritional intake, including
calories, fatty acids, protein, and vitamins, is
needed to promote wound healing” (Ackley &
Ladwig, 2011, p. 770)
Evaluation of Interventions
The interventions were successful in meeting the goal. The patient’s
(If not met or partially met
wound did not become infected or show dishescense. Proper
explain why):
assessment, positioning and nutrition were helpful in preventing
infection.
Problem/Nursing Diagnosis
(Psychosocial)
1.
2.
3.
Risk for anticipatory grieving related to ambiguous genitalia as
evidenced by the mother stating “we thought the baby was going
to be a girl, but it ended up being a boy” and “we already bought
all the stuff for a girl”.
Goal: The patient will verbalize that she has come to terms with the
gender of her baby by the end of the shift.
Interventions:
Rationales:
Identify behaviors that are suggestive of the
1.
“Mourning is associated with the
grieving process.
behavioral manifestations of grief. Grief
is an individual and exquisitely personal
experience” (Gulanick & Myers, 2011, p.
87).
Identify the availability of support systems for the
2.
“Social support has been shown to help
patient.
bereaved individuals” (Ackley & Ladwig,
2011, p. 412).
Concentrate on improving communication and
3.
“Communication within the family has
provide an environment for families to connect with
been shown to be a major predictor of
one another.
grief because it is an important
4.
component in the ability to share grief
and express feelings about the loss in a
supportive environment” (Ackley &
Ladwig, 2011, p. 412).
Discuss spirituality with the patient and her spouse. 4.
“Researchers have found a striking
correlation between good spiritual
health and good physical health.
Spiritual well-being may improve the
quality of life in clients” (Ackley &
Ladwig, 2011, p. 412).
Evaluation of Interventions
The interventions were successful in helping the patient come to
(If not met or partially met
terms with the gender of her baby. The patient stated “I guess this
explain why): just means we need to buy all new things” and “he is such a cute little
boy”. The patient and her husband were very open when talking
about their new little boy and stated how they have people from
their church that are praying for them and their new baby.
Problem/Nursing Diagnosis
(Knowledge Deficit)
1.
2.
3.
4.
Knowledge deficit related to breastfeeding as evidenced by the
baby not latching onto her breast and the patient saying “he
does not latch well onto my right breast”.
Goal: The patient will demonstrate correct breastfeeding techniques
for a good latch by the end of the shift.
Interventions:
Rationales:
Provide time for the patient to express expectations 1. “Lactation consultants and nurses play a
and concerns and give emotional support.
key role in the establishment of
breastfeeding” (Ackley & Ladwig, 2011,
p. 187)
Teach the patient to have a quiet atmosphere
2.
“A calm quiet environment assists the
without interruption. Promote comfort and
patient with concentrating more
relaxation to reduce pain and anxiety.
completely” (Gulanick & Myers, 2011, p.
117). “ Discomfort and increased tension
are factors associated with reduced letdown reflex and premature
discontinuance of brestfeeding” (Ackley
& Ladwig, 2011, p. 187).
Teach the patient to monitor infant behavioral cues 3. “Infant behaviors contribute to oxytocin
and responses to breastfeeding.
release and let-down, contribute to
effective feeding, indicate effective
breastfeeding, manifest satiety, and
indicate adequacy of the feeding while
contributing to positive maternal-infant
attachment” (Ackley & Ladwig, 2011, p.
187).
Provide the necessary instructions and resources to 4.
“Evidenced-based guidelines and
find a technique that works for this mother and her
systematic reviews support the use of
baby boy.
professionals with special skills in
breastfedding” (Ackley & Ladwig, 2011,
p. 187).
Evaluation of Interventions
The interventions were successful in helping the patient learn and
(If not met or partially met
demonstrate a good latch for her baby. She was assisted in trying
explain why): new positions to feed her baby and the football hold was found to be
the most effective way for her to breastfeed on both her breasts.
MEDICATIONS
ALLERGIES:
No Known Allergies
Medication
Strength/
Frequency
Mechanism
of Action
Why is the patient
on the medication
Side effects
Nursing
responsibilities
Colace
100mg BID
Stool softener
Diarrhea
-Observe for
diarrhea
Motrin
600 mg q6h
Relief from
mild to
moderate pain
The patient just had
surgery and had not
had a bowel movement.
The patient is taking it
for pain post-cesarean.
-Monitor patients
level of pain
-Monitor the
patient for reaction
Magnesium
Sulfate
50mL/hr
Blocks
neuromuscular
transmission
To help prevent
seizures
Headache, dizziness,
insomnia, nausea,
constipation,
agranulocytosis,
pancytopenia, aplastic
anemia
Weakness, dizziness,
magnesium
intoxication, depressed
reflexes
Labetalol
200mcg
Every
morning
Lowers blood
pressure
Patient had pregnancy
induced hypertension
Bronchospasm,
dyspnea, nausea,
vomiting
-Monitor the
patient for any of
the side effects
-Assist the patient
with any
ambulation
-Monitor the
patient’s blood
pressure and take a
new blood
pressure before
administering.
Student reflection:
This week was a bit of an adjustment period as it was not as fast paced as Labor and Delivery,
but also because I did not know what my role was in caring for postpartum women and their babies.
It took me a couple hours in the morning of following around my nurse and interacting with the
patients to finally feel more confident in my abilities as a postpartum nurse. Having no experience of
my own in being a mother, I felt a few steps behind the others in the clinical group, but I found my
love for talking with people and years of experience with kids and babies helped out greatly when
connecting with the patients. The moment I felt most proud was at the end of the day when I was
helping to clean up a baby and then swaddle him. The new dad stepped up behind me and asked if he
could watch how I swaddled the baby boy. Even though it was just swaddling a baby, I felt like I did
have something to contribute and was able to help out a first time dad who just wanted to learn how
to wrap his new baby. I learned that there is so much I have to contribute and to share with these
new parents. Watching and listening to my nurse instruct my patient on how to breastfeed more
effectively, helped me to learn how I can help another mom in the future. Next week I hope to
continue meeting the patient’s needs in anyway I can, whether it be through time spent with them
talking or teaching them.
Spiritual reflection:
This week during clinical I felt like I had a slower start to making a spiritual connection with
my patient. Due to the fact that I was working with my nurse’s three patients and also helping other
patients, I felt that I did not spend as much time in my patient’s room as I usually like. During the
time I was able to spend with my patient, I talked with her and her husband about their support
system and the big transition this was going to be for them as first time parents. We talked about the
church they were involved with and how many of the people were praying for them and their new
baby. They seemed to have a very firm foundation in Christ and it was neat to see that even during
this transition period and the surprise that they had when they discovered their baby was a boy, they
both felt very supported by their church body. One thing that I missed doing with this couple was
taking the time to pray with them before I left for the day. I usually make time for it before I leave for
the day, but I failed to do it with this couple. Often times I forget the power prayer can have.
Recently in bible study, my bible study teacher said, “Many times we say we are going to pray for
people, but then we forget or we do not follow through. I think the reason so many of us brush
prayer aside is because we forget the power it has to change our life and those around us” (Personal
Communication, 2013). I like this quote from O’Brien that says, “Prayer, whether formal or informal,
may be central to healing the sick. Healing prayer has been described as bringing oneself and a
situation of disease before God, with at least one other person to listen, discern, speak and respond,
so that healing in relation to or with God can take place” (O’Brien, 2011, p. 153). My priority for this
coming week is to spend time in prayer with my patient.
References
Ackley, B. J. & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning
care (9th ed.). St. Louis, MO: Mosby Elsevier.
Davidson, M., London, M., & Ladewig, P. (2012). Old's maternal-newborn nursing & women's health
across the lifespan. Upper Saddle River, NJ: Pearson.
Gulanick, M. & Myers, J. (2011). Nursing care plans: Diagnoses, interventions, and outcomes.
Philadelphia, PA: Elsevier.
Karch, Amy M. (2013). Lippincott’s nursing drug guide. Rochester, New York: Lippincott Williams and
Wilkins.
Lehne, R.A. (2013). Pharmacology for nursing care (8th ed.). St. Louis, MO : Saunders Elsevier.
McCance, K.L, Huether, S.E., Brashers, V.L. & Rote, N.S. (2010). Pathophysiology: The biologic basis for
disease in adults and children (6th ed.). Maryland Heights, MO: Mosby Elsevier.
O’Brien, M. E. (2011). Spirituality in nursing: Standing on holy ground, (4th ed.). Boston, MA:
Jones & Bartlett.
Potter, P.A. & Perry, A.G. (2012). Fundamentals of nursing (8th ed.). St Louis, MO: Mosby Elsevier.
Azusa Pacific University
GNRS 575
Grading Criteria
Sections
Criteria
Historical Information
Possible
Points
20%
Demographics and
specified growth and
BP parameters
Diagnosis (es)
All info present
2
Patient’s current priority diagnosis (es)
2
History of Present
Illness
Chronological account of patient’s current illness with pertinent
positive’s and negative‘s included and correct medical terminology
used.
Major illness, surgeries, traumas, known allergies, and birth
history (if appropriate) included.
Family medical and mental health Hx, composition of family, living
conditions, safety issues, smoking in home
History complete and correctly documented.
4
Past Medical History
Social/Family History
Obstetric History
Pathophysiology
Laboratory and
Diagnostic Tests
Medical Treatments
Problems or Nursing
Diagnoses with 1 goal
for each followed by
interventions and
evaluation criteria
Pathophysiology 25%
(1) Pathophysiological changes that occur in the current diagnosis
(es), (2) Explain how the concurrent diagnoses affect the priority
diagnoses. (3) Explain anticipated treatment.
(4) Highlight what diagnostic tests, treatments, or teachings are
currently being done for your patient.
Laboratory Values/Medical Treatments15%
Most recent and previous most recent lab test results with all
abnormal results explained.
Medical treatments listed and all rationales included.
Goals and Rationale for Treatment, Medications, & APA 40%
Two priority-nursing diagnoses listed with goals and related
interventions: there must be 1 physiologic and 1 psycho-social,
Include rationale for all interventions. Must be individualized to
the patient’s needs with evaluation of the effectiveness of the
interventions included.
Medications
Drug Class/MOA, onset and duration, side effects, dosage/ routes,
and nursing responsibilities included.
APA
Incorporates the entire writing process using resources. APA style followed
consistently, less than two APA errors are seen with page format. Paper is
written in a scholarly style.
All sources are correctly written in the in-text citation and on the
References page.
Total Points
4
4
4
25
10
5
10
(diagnosis)
10
(goals)
10
(int/
rationale)
5
5
100
Points
Earned