Case Study
Jessica Thompson
And
Erika Tallman
Demographics
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T.L.
29 years old
G6P5AB1L4
LMP 8/31/10
baby girl
6 lbs 7oz
Born 6/1/11 at 1709
39weeks and 1 day gestation.
EDD 6/7/11
Bottle feeding (Maternal preference)
OB history
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Pregnancy #1:was an ectopic pregnancy.
Pregnancy #2: resulted in the preterm labor at 36
weeks.
Pregnancy #3: resulted in another preterm labor
at 35 weeks.
Pregnancy #4: resulted in fetal demise at 32
weeks gestation related to cervical funneling.
Pregnancy #5: resulted in a full term baby boy.
Pregnancy #6: resulted in a full term baby
girl.
Fatal Pregnancies
 IUFD
Occurred at 32 weeks gestation
when cervical funneling (cone
shaped indentation in the cervical
os took place) which she birthed.
 Ectopic
Occurred when the ovum
implanted into a site other
than the lining of the uterus.
Incompetent cervix
 Painless
dilation of the cervix without
contractions because of a structural or
functional defect of the cervix.
 Related risk factors include: multiple
gestations and previous preterm births
 Education would include the warning
signs of preterm labor: lower back pain, pelvic
pressure, and changes in vaginal discharge; and the
benefits of a cerclage placement.
Cerclage
 Surgical
procedure in which the cervix is
sewn shut primarily in the third month
pregnancy (T.L. had this done at 13
weeks, laproscopically), to keep the
cervix from prematurely dilating.
 Successful in 80-95% of cases.
 Generally removed in the 37th week of
pregnancy, but can be removed earlier if
ROM or true labor contractions occur.
Cervical Cerclage, 2006
video
http://www.youtube.com/watch
?v=630Ax6N6yp0&feature=autopl
ay&list=PLB5A0A679455613C2&in
dex=1&playnext=2
(elitelaproscopic, 2010)
Ultrasound Criteria for the Diagnosis of
Incompetent Cervix
Normal Pregnancy
Cervical
Length
>3 cm
Cervical
Width
<2 cm
in second trimester.
Cervical
Canal
Width
<8 mm
Cervical
funneling
Bulging of
Membranes
into
cervical
canal
Cervical incompetence
<3 cm
>2 cm
in second trimester.
>8 mm
None or
< 25%
25-50% or
> 50%
None
Present
± fetal parts
J. Ludmir
PP Bilateral tubal ligation
“having your tubes tied”
 Permanent,
irreversible form of
birth control that is over 99%
effective.
 Procedure includes making an
incision just above the navel and
using laparoscopic tools to snip
the fallopian tubes and cauterize
them, pain is relieved through the
use of anesthesia.
 Can be done in an outpatient
setting.
Lab work
Test
Normal
Blood work
Type &Rh
Hemoglobin &
hematocrit
PT result
analysis
Maternal :O+
Baby: B+
Risk for ABO
incompatibility, may
cause newborn
jaundice R/T
hemolysis;
hyperbilirumia. Rh is
not an issue.
11mg/dL & 33% 11.5mg/dL &
in pregnancy
34%
No issues
VDRL/ RPR
Negative
No risk to fetus
Rubella
Immune
No risk to fetus
GC-C
Negative
No risk to fetus
positive
Treatment given:
penicillin X 2
Other
GBS
negative
Pregnancy Related tests
Test
Normal
Pap smear
PT Result
Analysis
Normal
No STIs or cancer
1 hr Glucose
tolerance
<130mg/dL
129mg/dL
No GDM
Biophysical
Profile
8-10
9
Fetal wellbeing
NST
2 accelerations Reactive
of at least 15
bpm for 15
seconds within
20 mins
Fetal wellbeing
Labor and Delivery
 T.L’s
labor was induced when her
Cerclage was removed on 5/31/11 and
amniotomy at 1915, with an epidural, LR
with pitocin, and a foley bulb, her labor
took 22 hrs, with a 9 minute 2nd stage and
a 3 minute 3rd stage, with 250mL blood
loss and a 2nd degree laceration.
 Because T.L. was gbs+, she was also
taking penicillin via a IV piggyback.
Labor and Delivery
contd.
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FHR remained in the 130s
bpm with moderate
variability, monitored
consistently with an
external transducer.
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The baby girl scored a 9
out of 10 on the APGAR
scale at 1 and 5 minutes
of age.
PP assessment
Vitals
 0900: BP 124/76, HR
70, R 14, T 36.7
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Pain 0/10
1400:
BP 122/74, HR
66, R 14, T 36.5
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Pain 4/10medicated with
vicodin and motrin
 BUBBLE-HEB
was
within normal limits
Newborn assessment
Vitals
 0800: HR 140, R 45, T
36.5
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Pain 0/10
1500:
36.5
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HR 150, R 45, T
Pain 0/10
 Reflexes
present
 Skin and mucosa
within normal limits
 fontanels soft and
level
 Symmetrical
movements
 Voiding
adequatelt
Newborn Feedings
 T.L.’s
choice to not breastfeed, the baby
girl now gets her nutrition through Similac
advanced formula every 3-4 hours.
 Feedings
1.
2.
3.
4.
5.
0530- 22cc
0900- 20cc
1130-5cc
1300-5cc
1530- 5cc
PP medications
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Vicodin: Opiod analgesic, generalized CNS depression
for moderate pain.
1 tab (5mg) q4hr PO : not to exceed
4000mg/day.
Prenatal vitamin: with iron supplement.
1 tab/day
Motrin: nonopiod analgesic/nonsteroidal antiinflammatory/ antipyretic: inhibits prostaglandin
synthesis.
Prn: 600 mg q6hr PO
Americaine ointment: anesthetic, local pain relief
Prn applied topically
Tucks(witch hazel) pads: analgesic, local pain relief R/T
hemorrhoids.
Prn applied topically
education
Nursing Diagnosis #1
Risk for infection
AEB… inadequate primary defenses, invasive
procedures and environmental exposure.
• Normal labor trauma
• Tubal procedure
• Not as active
• Hospital environment
Goal: Be free of purulent drainage or
secretions, and other signs of infections
throughout the healing process.
Evaluation: At this time the patient was free of
infection and expressed understanding of
education.
Intervention 1
Monitor and educate on the
following for signs of infection:
■Redness, swelling, increased pain,
or purulent drainage at incisions,
injured sites, exit sites of tubes,
drains, or catheters Any suspicious
drainage should be cultured;
antibiotic therapy is determined by
pathogens identified at culture.
■Elevated temperature Fever of up
to 38° C (100.4° F) for 48 hours after
surgery is related to surgical stress;
after 48 hours, fever above 37.7° C
(99.8° F) suggests infection; fever
spikes that occur and subside are
indicative of wound infection; very
high fever accompanied by
sweating and chills may indicate
septicemia.
■Color of respiratory secretions
Yellow or yellow-green sputum is
indicative of respiratory infection.
■Appearance of urine Cloudy, foulsmelling urine with visible sediment is
indicative of urinary tract or bladder
infection.
Check and
chart vitals
every shift for
comparison.
Give written
information
about signs of
infection
Physician should
be notified of
any signs or
symptoms of
infection
Intervention 2
Teach patient or caregiver to
wash hands often, especially
after toileting, before meals,
and before and after
administering self-care.
Patients and caregivers can
spread infection from one part
of the body to another, as well
as pick up surface pathogens;
hand washing reduces these
risks.
Note patient
compliance of
proper perineal
cleanser and
hygiene
Wash hands
before and
after client
care
Note patient
understanding
of education
given
psychological
Nursing Diagnosis #2
Risk for disturbed body image
AEB… situation, focus on past
appearance, change in social
involvement
• Multiple pregnancies
• 40 lbs weight gain, wishes to lose all
• Newborn to care for
Goal: improve and maintain self-esteem
through the first post-partal year illustrated
verbally.
Evaluation: At this time the patient is
unsatisfied with current body weight and
BMI illustrated by verbal negativity.
Intervention 1
Note patient’s behavior
regarding actual or
perceived changed body
part or function. There is a
broad range of behaviors
associated with body
image disturbance, ranging
from totally ignoring the
altered structure or function
to preoccupation with it.
Give
information
about realistic
weight loss
goals
Allow patient to
initiate
conversation
about subject of
her body
Promote patient
to communicate
concerns with
family and
healthcare
provider
Intervention 2
Assist patient in
incorporating actual
changes into ADLs,
social life,
interpersonal
relationships, and
occupational
activities.
Opportunities for
positive feedback and
success in social
situations may hasten
adaptation
Discuss healthy
nutritional and
physical
activity options
Be positive in
conversations
Give information
pertaining to
breastfeeding and
the extra calories
burned along with
the importance for
the newborn
nutrition
Nursing Diagnosis #3
Newborn: imbalanced nutrition: less
than body requirements
AEB… lack of interest in food
• Decreased intake
Goal: maintain and increase weight,
be free of signs of malnutrition daily
and throughout early childhood
Evaluation: At this time the patient is
not having adequate intake
Intervention 1
Monitor laboratory values
that indicate nutritional wellbeing/deterioration:
Serum albumin: This indicates
degree of protein depletion
(3.8 to 4.5 g/dl is normal).
Transferrin: This is important
for iron transfer and typically
decreases as serum protein
decreases.
RBC and WBC counts: These
are usually decreased in
malnutrition, indicating
anemia and decreased
resistance to infection.
Serum electrolyte values:
Potassium is typically
increased and sodium is
typically decreased in
malnutrition
Draw labs
once daily for
evaluation
Document
any values off
baseline/norm
and notify
physician
Evaluate any
supplemental
options if lab
values are
abnormal
Suggest ways to assist
patient with meals as
needed. This educates
and encourages
adequate feedings.
Ensure a pleasant
environment, to
improve comfort levels
both maternally and for
the newborn. facilitate
proper positioning;
nipple placement and
a proper latch
facilitates feeding and
provide good oral
hygiene to reduce risk
of aspiration
Intervention 2
Encourage
frequent and
possible
smaller meals
Monitor
weight gain
and I&O
Make sure
formula is at a
comfortable
temperature,
and nipple is
appropriate
physiological
Nursing Diagnosis #4
Disturbed sleep pattern
AEB… situation and environmental
changes
Previously prescribed sleep aide
• Hospitalization
• Newborn at home
• 4th child living in household
Goal: Verbalize increased sense of wellbeing and adequately rested within
discharge and by the first follow-up doctors
appointment
Evaluation: At this time the patient is not
getting adequate rest, illustrated verbally.
Intervention 1
Identify factors that
may facilitate or
interfere with normal
patterns. Knowledge
of its role in
health/wellness and
the wide variation
among individuals
may allay anxiety,
thereby promoting rest
and sleep.
Allow mother
alone time to
rest when she
chooses
Provide
comfort
measures that
assist in
relaxation
Evaluate and
educate on
help from family
and friends
once at home
Intervention 2
Instruct patient to
follow as consistent a
daily schedule for
retiring and arising as
possible. This promotes
regulation of the
circadian rhythm, and
reduces the energy
required for adaptation
to changes.
Monitor current
sleep pattern and
consult with
physician for
pharmacological
measures if
needed.
Discuss sleep
patterns
effective with
previous
pregnancies
Provide
information on
the importance of
sleep and various
tricks to allow for
adequate sleep.
References
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(2006). In Cervical Cerclage. Retrieved Jun.
7, 2011, from
http://www.americanpregnancy.org/pregna
ncycomplications/cervicalcerclage.html
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Body Image Disturbance; Weight training
may be effective for body- imaged-disturbed
college women :[1]. (2004, November).
Obesity, Fitness & Wellness Week,141.
Retrieved June 13, 2011, from ProQuest
Nursing & Allied Health Source. (Document
ID: 738930181).
Gulanik, Myers, Klopp, Galanes,. (2009). In EHS:
Nursing Care Plans: Diagnosis and Intervention.
Retrieved Jun. 8, 2011, from
http://www1.us.elsevierhealth.com/MERLIN/Gula
nick/Constructor
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Harmat, L., Takács, J., & Bódizs, R.. (2008). Music
improves sleep quality in students. Journal of
Advanced Nursing, 62(3), 327. Retrieved June 13,
2011, from ProQuest Nursing & Allied Health
Source. (Document ID: 1468397021).
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Louey, M.. (2006). Formula Feeding: Fluid
Evidence Summaries. Retrieved June 13, 2011,
from Evidence-Based Resources from the Joanna
Briggs Institute. (Document ID: 1445804761).

Ludmir, J. In Ultrasound Criteria for the Diagnosis
of Incompetent Cervix. Retrieved Jun. 8, 2011,
from
http://www.fetalultrasound.com/online/text/33039.htm
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Stulberg JJ, Delaney CP, Neuhauser DV, Aron
DCm FU P, Koroukian SM. Adherence to Surgical
Care Improvement Project Measures and the
association with postoperative infections. JAMA.
2010; 303(24): 2479-2485.
Doenges, M, & M. Moorhouse, & A. Murr.
(2010). Nursing Care Plans: Guidelines for
Individualizing Client Care Across the Life
Span. Philidelphia, PA: F.A. Davis.
elitelaproscopic,. (2010, Mar. 3 ). In
Laproscopic Cervioc-Isthmic Cerclage.
Retrieved Jun. 7, 2011, from
http://www.youtube.com/watch?v=630Ax6N
6yp0&feature=autoplay&list=PLB5A0A679455
613C2&index=1&playnext=2
Fogelson, N.. (2010, Feb. 27 ). In Cerclage
How-To . Retrieved Jun. 7, 2011, from
http://academicobgyn.com/2010/02/27/ac
ademic-obgyn-cases-abdominal-cerclagehow-to