SAMUEL MERRITT UNIVERSITY ABSN STUDENT: Liz Wagstaffe PRESENTING S/SX ON ADMISSION (REASON FOR SEEKING CARE) Date/Day/Week: Sunday, 10.30.22 STUDENT GOALS FOR THE WEEK 1. Practice Postpartum / Newborn assessments and complete check-off 2. Complete OB Medication review 3. Assist L&D nurses with patient care PERTINENT LAB DATA: ADDITIONAL LABS: Blood type: O positive Rubella: immune Vaginal bleeding and contractions with suspected placental abruption PATIENT PROFILE (SYNOPSIS) PATHOPHYSIOLOGY OF ADMITTING DX & COMPLICATIONS MED. ALLERGIES: no known allergies CURRENT MEDS: (ARRANGE BY TIME) DRUG/DOSE Nifedipine / 10mg Magnesium Hydroxide / 400 mg Colace / 100mg Prenatal Vitamin / 1 tablet Nifedipine / 20mg Nifedipine / 20mg CURRENT IV INFUSION(S): N/A - IV saline loc 1 TIME 0600 0900 0900 0900 1200 1600 INITIALS PT AGE 35 SEX F ADMISSION DATE: 10/7/22 ADMITTING DX: Placental abruption CODE STATUS: Full ADMISSION WT. 56.8 Kg Patient is a G2P0, 33w3d (12/15/22) admitted to antepartum on 10/7. She presented with vaginal bleeding and reported passing quarter sized clots. On admission she was contracting q3 minutes. She was admitted and observed 9/23 - 9/30 for bleeding and diagnosed with placental abruption. Bleeding CURRENT WT. 59.3 Kg ceased and she was discharged home to rest. Bleeding resumed on 10/7 and she was admitted for the duration of her pregnancy until delivery. The date of last bleeding is 10/19. She is being monitored for BMI: 22 ongoing contractions. The treatment plan for this patient is continuous monitoring, minimize/prevent DIET: (ORAL/ENTERAL/TPN) contractions, and monitor for bleeding. Patient was treated with IV Magnesium Sulfate to control normal diet contractions and for fetal neuroprotection. As of today, patient is on an increased dose of Nifedipine DIETARY RESTRICTIONS: none (20mg q4h) to control ongoing contractions. She reports no bleeding. Patient is resting in bed and can ambulate safely to the toilet. Plan for this patient is to remain in antepartum until delivery. Provider FOOD ALLERGIES: none recommends delivery at 36 weeks. GBS: negative DIAGNOSTIC TEST RESULTS PT. DATA ACTIVITY ORDERS: In-patient until delivery at 36 weeks TREATMENT SCHEDULE: Continue Nifedipine 20mg q4h, as tolerated. Placental abruption is the rupture of blood vessels that attach the placenta to the uterine wall. This results in bleeding and diminished blood flow to the placenta placing both the pregnant patient and the MEDICAL HX: no pertinent past medical fetus at risk.1 history Risks to the fetus include impaired gas exchange, hypoxia, diminished nutrients and death. Risks to the SURGICAL HX: no pertinent past surgical pregnant person induce hypotension, hypovolemia and excessive blood loss. (Nelson, 2013) history Predisposing risk factors include trauma, hypertension, polyhydramnios, cocaine use, chorioamnionitis, SOCIAL/FAMILY/PSYCH HX: smoking, intrauterine growth restriction, and a history of abruption. (Nelson, 2013) Husband is with patient in the hospital. Other Signs and symptoms of this condition include abdominal pain, bleeding, contractions and a persistently family members visit patient regularly. firm uterus on palpation. (Nelson, 2013) Pregnant patient symptoms may include hypotension and IMPORTANT GOALS FOR PATIENT excessive blood loss. Fetal symptoms may include tachycardia/bradycardia and late decelerations. CARE (Nelson, 2013) Monitor contractions and ask patient if she experiences any pain or notices any changes. Monitor for bleeding and educate patient to alert nurse to any bleeding. Avoid constipation and straining. Nelson, Kayla (2013, Sept. 5). Placental Abruption: risk factors, pathogenesis, and clinical findings. The Calgary Guide to Understanding Disease. https://calgaryguide.ucalgary.ca/placental-abruption/ OBJECTIVE DATA: ASSESSMENTS N LOC/Orientation:_AO x 4______________________________________________________________________ E Motor:_in tact______________________________________________________________________________ U Senses: in tact______________________________________________________________________________ R Pain c/o & Tx:_0 / 10____________________________________________________________________ O Other: M ROM:_full ROM / in tact________________________________________________________________________ S Activity level:_resting in bed, minimal activity . ADL: patient can manage independently NURSING DX (validated by obj. data) 1. Risk of intrapartum hemorrhage 2. Risk of preterm labor OUTCOMES/GOALS 1. patient will not experience any bleeding during shift Other: C Heart Rate: 71 Rhythm: normal sinus rhythm Murmurs: n/a V Pulses: strong 2+ bilaterally (radial, dorsalis pedis) Edema: no edema Other: R Breath Sounds: clear bilaterally, no adventitious sounds E Oxygen: room air S Resp. Tx.: n/a P Cough: n/a O2 Saturation: 98 Other: Bowel Sounds: present I Abdomen: gravid Flatus/Last BM date 10/30 Feeding tubes/solution: n/a Diet: normal Toleration: tolerates 24 hour Oral Intake: unmeasured Usual blood Glucose: 98 Other: G Void/ Foley: void independently Color: yellow Output: unmeasured U Other: S Dressings, incision/ wound/ lesions (location and condition): erythema on R forearm close to IV site, IV to be K removed and changed to new site I _____________________________________________________________________________________ N Other: _______________________________________________________________________________ P Psycho- emotional issues/concern: risk of isolation and depression related to extended hospital stay s Family support system: husband and extended family members present y Other: DISCHARGE PLANNING/TEACHING Patient asked about 72 hour type and screen labs. Educated patient on the need to maintain current records to ensure the correct blood products are available in case of an emergency. 1. Areas of Strength: Comfortable with patient care and supporting ante/intra/postpartum patients h/ VITAL SIGNS: T= 98.4 RR= 16 1. No reports of bleeding, no evidence of bleeding, safe administration of medications 2. contractions are stable or become less frequent, no signs of progressive labor IDENTIFY 2 COURSE OBJECTIVES MET THIS WEEK 1. Assisted with antepartum assessment, vitals, and repositioning patient 2. Complete postpartum and newborn skills check-off STUDENT SELF EVALUATION: c Baseline: BP=120/ HR= 105 64 EVALUATION 2. ● administer Nifedipine to reduce smooth muscle contractility of uterus ● Encourage patient to continue resting in bed ● Assist patient to reposition q2h ● Continuous tocodynamometer and FHM monitoring Sputum: n/a IS: 10x/hour G INTERVENTIONS & RATIONALE 1. ● administer Nifedipine to reduce uterine contractility ● Encourage patient to rest in bed unless ambulating to toilet ● Administer stool softener to prevent constipation and straining ● Educate patient to notify nurse if there are any signs of bleeding O2 Sat= 100 Pain=0 2. Areas to work on: Continue to identify areas where I can contribute hands-on and gain more skills. Inquire about opportunities and ways to practice IV starts, foleys. Continue to pursue deeper substantive knowledge.
