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D.S. Case Study
Eric Manson and Emily Dehnke
Kent State University Stark
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D.S. Case Study
Introduction
On July 8, 2010, Eric and I shared a patient with the initials D.S., who was a 35 year old
caucasian female. She had no known allergies. This pregnancy was the 5th time she had been
pregnant, but she only had two living children (including the child just born). In other words,
she was a gravida five, para two. She had a baby boy on July 7, 2010 at 0034. She had to have a
caesarian section due to the fact that the baby was not tolerating the delivery well and had steristrips on the transverse incision. The baby was 37 weeks and 1 day gestational age, which is
considered preterm. He weighed seven pounds and eleven ounces. The baby was being bottle
fed. The mother and father were both very active in the care of their new baby boy as well as the
patient’s mother. They all seemed very excited for the new baby.
We chose this patient to analyze for our case study because of her unique medical history
as well as her current pregnancy information and assessments. Her information and situation
were very relevant to what we are learning in our maternal-newborn lecture class and clinical.
We wanted to apply what we have learned thus far to help us to dig deeper into the interesting
information presented to us about our patient, D.S.
The purpose of this paper is to gain knowledge in maternal-newborn nursing care. This
clinical rotation has really challenged us in a specialty area we know little about and we were
eager to know more. We wanted to analyze our patient, her history, and assessments in order to
get a full understanding of the dynamics of what affects pregnancy and the prenatal stage. We
also wanted to use our patient’s information in order to practice planning nursing care by
choosing diagnoses relevant to our patient and her newborn as well as determining interventions
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in order to meet a specific goal relating to each diagnosis. By writing this paper, we hope to gain
valuable knowledge in the specialty area of maternal-newborn nursing.
Demographics
D.S. is a thirty five year old Caucasian female. She is 5 foot seven inches and weighed
one hundred and forty one pounds before pregnancy. She is married and has two children. One
is a three year old boy and the other is a baby boy born July 7, 2010. D.S. and her family live in
Canton, Ohio. D.S., her husband, and mother are all very active in the care of her children. D.S.
has a high school diploma and has finished one year of college in the field of accounting. She is
a stay-at-home mom and currently is unemployed. Her husband works for an insurance
company. They are looking into WIC, which is a food program for women, infants, and children
to assist low-income women and their children under age five (Davidson, London, and Ladewig,
2008). Her prenatal care was all done at the Stark County Women’s Clinic in North Canton,
Ohio. She does not have a religious affiliation. She also does not smoke, drink, or have any
history of substance abuse.
OB and Antenatal History
D.S. has some very interesting and pertinent OB and antenatal history. She is a gravida 5
para 2. This means that she has been pregnant five times, but only has two living children. The
other three pregnancies ended in spontaneous abortions, or miscarriages. This is significant
because chances of successful pregnancy decrease with each succeeding abortion (Davidson et
al., 2008). Also, when there are two or three miscarriages, a woman and her partner should be
evaluated and are encouraged to participate in genetic counseling (Davidson et al., 2008).
Another aspect of D.S.’s OB history that would encourage her to get genetic counseling is the
fact that her sister had a child with Down syndrome. Also, D.S. is thirty five years old and the
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chance of Down syndrome and other genetic defects occurring increases with advanced maternal
age (Cummings, 2005). D.S. and her husband have no record of genetic counseling. D.S. also
declined the triple screen test, or multiple marker screening (MMS), which is a serum test done
at sixteen to eighteen weeks gestation. It evaluates three factors, which are maternal serum
alpha-fetoprotein (MSAFP), estriol, and hCG ((Davidson et al., 2008). It is essentially a
screening test for neural tube defects, genetic mutations such as Down syndrome and Trisomy
18, and Rh disease (Davidson et al., 2008).
D.S. has a history of Chlamydia, which is the most common sexually transmitted
infection (STI) in the United States (Davidson et al., 2008). It can infect the fallopian tubes,
cervix, and urethra and can cause infertility, PID, and ectopic pregnancy (Davidson et al., 2008).
D.S. did not have Chlamydia during her pregnancy and it did not affect her pregnancy in any
way. D.S. also had a urinary tract infection (UTI) at twenty weeks gestation, which is normal
because UTIs are more frequent in pregnant women because of the dramatic physiologic changes
that occur in a pregnant woman’s body (Davidson et al., 2008). A cause of a UTI could be
Asymptomatic bacteriuria (ASB), which is bacteria in the urine that multiplies without causing
any symptoms of an UTI (Davidson et al., 2008). ASB is associated with low birth weight,
preterm birth, hypertension, preeclampsia, maternal anemia, and symptomatic UTI (Davidson et
al., 2008). UTIs can develop into pyelonephritis (inflammation of the kidney), which can lead to
preterm labor, preterm birth, septicemia, and intrauterine growth restriction (Davidson et al.,
2008). Luckily, D.S.’s UTI was caught early and treated quickly. D.S. also had a cervical polyp
removed on March 31, 2010.
Cervical polyps during pregnancy are common, especially among
women over twenty years old who have had at least one child (Panayotidis & Alhuwalia, 2009).
Pregnant women can be concerned about polyps because of recurrent bleeding, risk for infection,
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premature labor, delivery difficulties, or increased risk of bleeding during labor (Panayotidis &
Alhuwalia, 2009). Because of these concerns, D.S.’s polyp was removed.
D.S. also has a history of preterm delivery, which is delivering a baby before thirty eight
weeks gestation (Davidson et al., 2008). This predisposes her to increased risk for another
preterm delivery. In 1993, D.S. suffered from anorexia nervosa. This is a psychological disease
in which a woman strives for control, has decreased appetite, thinks she is fat and/or obese, is
below minimal weight for her height, and has not had menses for three months (James, 2009). It
is a very dangerous condition for overall health as well as reproductive health and women with
anorexia are at increased risk for depression (James, 2009). Although pregnancy in women with
anorexia is highly unlikely due to lack of menses, these rare pregnancies are prone to
complications such as more hospitalizations of the pregnant woman, low weight gain in the
mother, increased infant mortality rates, preterm delivery, low Apgar scores, low birth weight,
higher incidence of Caesarean delivery, and increased risk for abnormal physical development
(James, 2009). Luckily, D.S. only had a small amount of time where she was anorexic and was
able to get pregnant and deliver a healthy baby boy.
The last very important aspect of D.S.’s OB history to mention is her history of
postpartum depression (PPD) in 2007 after her first son was born. PPD, or postpartum major
mood disorder, occurs in 8%-20% of postpartal women (Davidson et al., 2008). The signs and
symptoms of PPD are similar to major depression including sadness, frequent crying, sleep
disturbances, appetite changes, difficulty concentrating, lack of interest in activities, thoughts of
inadequacy, constant anxiety, a feeling of being out of control, and suicidal thoughts and/or
attempts (Davidson et al., 2008). It can also include hostility and irritability towards other
people including the newborn (Davidson et al., 2008). It is distinguishable from postpartum
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blues by lasting more than two weeks. If left untreated PPD could develop into postpartum
psychosis which has a greater risk of suicide and/ or infanticide (Davidson et al., 2008). D.S.
showed no signs of PPD while in the hospital.
Assessment
On July 8, 2010 D.S.’s assessment was performed early in the afternoon. It was her
second day post-op following her c-section. Her apical pulse was 72, respirations were 18, blood
pressure was 105/65, temperature was 36.4 C, and her pain level was a seven. We were a little
concerned with her low blood pressure, but after asking the patient and looking at her chart, we
determined that she had a naturally low blood pressure. We also were concerned about her pain
level, so we medicated her with one Motrin and two Percocet, which brought her pain level down
to a three. She was alert and orientated times three and her verbal and motor responses were
within normal limits. Her heart rate was within normal limits and she had a regular rhythm. She
had slight edema in her feet and her pedal pulses were +1 bilaterally. Her respirations were
unlabored and with a regular rhythm. Her lungs were clear and breath sounds were equal
bilaterally with no cough. She was bottle feeding the baby and her breast were soft and without
pain. The uterus was firm and midline and positioned at the umbilicus. She was voiding and
eliminating adequately. She had a light amount of rubra lochia. Her perineum was intact due to
her c-section and she had no hemorrhoids. Her incision was well-approximated and the steristrips were clean and dry. She reported no leg or calf pain and there was no redness or warmth.
Her emotional status was appropriate; she was very accepting of the new baby but was being
closely monitored due to her history of postpartum depression. She was bonding appropriately
with her baby; she was changing the baby’s diapers, feeding the baby, talking to the baby, and
examining all the baby’s parts.
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The baby’s assessment was performed after the mother’s. His vital signs were as
follows; apical pulse 143, respirations 66, and temperature 36.8 C. Although the respiration rate
was a little higher than normal, we alerted our clinical instructor and she said the rate was ok.
His heart rate was normal and the rhythm was regular. The lungs were clear and the breathing
pattern was irregular and unlabored. The anterior and posterior fontanels were soft and level
with the skull. His skin was warm, dry, and pink with skin turgor < 3 seconds. The femoral and
pedal pulses were bilateral and equal. His mucous membranes were moist, pink, and clear. The
abdomen was soft and round with bowel sounds present in all four quadrants. The umbilical
cord was black and drying. His extremities were symmetrical with full range of motion. The
Moro, rooting, Babinski, and suck reflex were all present. During the assessment the baby did
not cry but later in the shift the baby’s cry was strong. The baby was feeding every three to four
hours while consuming 1 ounce to 1 ½ ounces of Similac Advance with each feeding. He was
also voiding and eliminating adequately.
Lab Results and Analysis
Upon the first prenatal visit D.S. would have had blood drawn. One of the tests done is
to determine blood type. D.S.’s blood type is A-. This means that her blood type is A and she is
Rh negative. Since her husband is Rh positive there is a chance that the baby will be Rh positive
and that creates a risk for fetal blood to come in contact with the mother’s blood causing her to
produce Rh antibodies. The Rh antibodies would not affect this pregnancy but if D.S. were to
become pregnant again with an Rh positive baby it could cause serious complications. The Rh
antibodies in the maternal blood would attack the Rh antigens in the fetal blood and destroy fetal
red blood cells. This can lead to fetal anemia, edema, and congestive heart failure which could
result in death of the fetus. Neurological damage can also result from the red blood cell
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destruction which causes hyperbilirubinemia and jaundice (Davidson et al., 2008). To prevent
DS from developing Rh antibodies she was be given RhoGAM between 26 and 28 weeks and
after giving birth.
Another part of the blood test is to check the hemoglobin and hematocrit levels. The
hemoglobin is responsible for transporting oxygen in the blood and is how the fetus receives
oxygen also. D.S. had a normal hemoglobin level of 12.7 g/dl; normal range for a female is 1216 g/dl. The hematocrit level gives the percentage of red blood cells that is in a given volume of
blood. D.S.’s hematoctrit was 36.6%, which is lower than normal and is a result of physiologic
anemia. This is when the plasma levels increase greater in pregnancy than the red blood cell
levels which cause a decreased percentage of red blood cells (Davidson et al., 2008).
D.S. was also tested for a variety of sexually transmitted diseases which she tested
negative to all. The diseases tested for are syphilis, chlamydia, and gonorrhea. If positive the
mother would be placed on an antibiotic to treat the mother to prevent infection of the infant.
The VDRL/RPR test is done to test for syphilis. A fetus infected with syphilis could lead to
anything from spontaneous abortion, stillborn infant, an infected infant, or an unaffected live
infant. If chlamydia or gonorrhea is left untreated it could cause eye infections to the newborn if
delivered vaginally. Chlamydia can also cause chlamydial pneumonia, premature labor, and
fetal death (Davidson et al., 2008).
Blood was also drawn to evaluate if D.S. has immunity to the rubella virus. Her lab test
showed that she is immune to the rubella virus. Pregnant women who are not immune are
instructed to stay away from other with rubella or symptoms of rubella since pregnant women
cannot receive the rubella vaccine. A pregnant woman who comes in contact and acquires the
rubella virus puts the fetus at a high risk of developing abnormalities (Davidson et al., 2008).
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Another part of D.S.’s prenatal lab work is a urine culture and sensitivity and a PAP test.
The urine culture and sensitivity is done periodically to test for urinary tract infections. Urinary
tract infections can lead to pyelonephritis (inflammation of the kidneys), urine irritability, and
preterm labor. The PAP test, or Pap smear, is done by collecting cervical cells and examining
them for abnormalities. If the Pap smear comes back positive then a LEEP (Loop electrosurgical
excision procedure) procedure may be done to remove a portion of the cervix. This can lead to
cervical incompetence with following pregnancies (Davidson et al., 2008). D.S.’s PAP test came
back negative and no interventions were necessary.
Between the 16th and 18th week of pregnancy D.S. had a 1 hour glucose tolerance test.
This is a screening test to determine if a 3 hour glucose tolerance test is necessary to diagnose
gestational diabetes mellitus. Gestational diabetes mellitus is an intolerance to carbohydrates
which can lead to complications to the pregnancy. D.S.’s result for her one hour glucose
tolerance test was 87 mg/dl. If the results for the one hour glucose tolerance test come back
higher than 130-140 mg/dl then the patient would take the three hour glucose tolerance test to
determine if they were a gestational diabetic (Davidson et al., 2008).
D.S. was also tested for group B streptococcal (GBS). GBS is a bacterial infection that
can be transmitted to the fetus. GBS can lead to sepsis to the infant and can be fatal. Women
who test positive for GBS are given antibiotics to prevent maternal infection during childbirth
and to prevent transmission of the bacteria to the fetus (Davidson et al., 2008). D.S. tested
negative for GBS.
Upon admission, at 1929, to the hospital D.S. tested positive for fetal fibronectin (fFN).
Fetal fibronectin is a glycoprotein produced by fetal tissues which is an indicator of premature
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labor or premature rupture of membranes (Davidson et al., 2008). D.S. had a spontaneous
rupture of her membranes at 2342.
Medications
Before D.S. became pregnant she received a vaccination for the H1N1 influenza. The
vaccine was given to provide antibodies to the H1N1 strain of influenza. It was given as an
intramuscular injection in her deltoid to prevent illness to this strain of influenza and to prevent
injury to the fetus if D.S. would become infected with H1N1 during pregnancy.
D.S. also stopped taking cymbalta on November 13, 2009. Cymbalta is an antidepressant
which works by inhibiting serotonin and norephinephrine. The use of this medication during the
3rd trimester of pregnancy may lead to the infant developing serotonin syndrome.
Due to D.S.’s history of preterm labor and spontaneous abortion she was given injections
of progesterone throughout her pregnancy (She received 7 doses between 4/15 – 6/16).
Progesterone is a hormone that is vital in maintaining pregnancy. It prevents the uterus from
contracting which in turn prevents preterm labor and spontaneous abortion. Progesterone also
keeps the lining of the uterus thick to maintain the pregnancy (Davidson et al., 2008). D.S. was
receiving progesterone through an intramuscular injection which was given in her right or left
hip. She was receiving 250 mg/ml. According to Deglin and Vallerand (2007) a nurse should
“Advise patient to report signs and symptoms of fluid retention (swelling of ankles and feet,
weight gain), thromboembolic disorders (pain, swelling, tenderness in extremities, headache,
chest pain, blurred vision), mental depression, or hepatic dysfunction (yellow skin or eyes,
pruritis, dark urine, light colored stools) to health care professional” (p. 1017).
Because D.S.’s blood type is Rh negative and her husband is Rh positive she was given
RhoGAM. RhoGam is an immunizing agent first given between 26 and 28 weeks and within 72
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hours after giving birth to prevent the mother from developing Rh antibodies. The RhoGAM
prevents hemolytic disease of the newborn in following pregnancies. If D.S. was left untreated
the Rh antibodies could cross the placenta in subsequent pregnancies and attack the fetal red
blood cells with the Rh antigen (Rh positive fetus) causing injury to the fetus (Davidson et al.,
2008). DS received one standard dose of 300 mcg by intramuscular injection between 26 and 28
weeks gestations and she also received the same dose on July 8, 2010. RhoGAM should be
given if there is any doubt regarding paternity or infant blood type.
At 21 weeks gestation D.S. received celestone solupan.
Celestone solupan is a
corticosteroid used to increase lung maturity and decrease the incidence of respiratory distress
syndrome for the fetus. This medication is given to mothers who are at risk for premature labor
to mature the lungs of the fetus resulting in fewer respiratory compilations on the preterm infant.
Celestone solupan should be administered deep into the gluteal muscle.
It should not be
administered into the deltoid due to the increased chance of local atrophy. Birth should also be
delayed at least 24 hours after taking this medication (Davidson et al., 2008).
D.S. was also taking a prenatal vitamin during her pregnancy. These vitamins are usually
taken daily by mouth. Prenatal vitamins are used to ensure the mother is getting the adequate
amount of essential vitamins to promote proper fetal development and to prevent certain
deformities such as neural tube defects.
During labor D.S. received an epidural. An epidural is when an anesthetic, bupivacine, is
injected into the lumbar region of the back into the epidural space that is between the dura matter
and the ligamentum flavum. The epidural is done to relieve pain while keeping the mother alert
to her surroundings so the mother can be aware of what is going on and can still bond with the
baby immediately after birth. Most women who have an epidural report complete pain relief but
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a small number of women report no relief of pain from the epidural. Before a patient receives an
epidural they are given IV fluids (usually 2 L). The fluids are given to combat hypotension that
occurs from peripheral vasodilatation as a result of the epidural.
Epinephrine which is a
vasopressor can also be given to reduce the risk of hypotension. While the mother is receiving
the epidural her vital signs are check frequently for a drop in blood pressure, heart rate, and
respirations. The fetal heart rate is also assessed for a loss of variability or a drop in fetal heart
rate. After the epidural the mother would be assisted to the restroom at least twice to ensure that
all sensations have returned to the mother’s legs and to determine if the mother is voiding
adequately. An epidural can cause a loss of the sensation of a full bladder and if the bladder is
left full over an extended amount of time the uterus will not contract as it should and there will
be an increased risk of hemorrhage to the mother (Davidson et al., 2008).
After the birth DS received Motrin. Motrin is a nonopioid analgesic that decreases pain,
decreases inflammation, and lowers fever by inhibiting prostaglandin synthesis. Patients should
not exceed 3600 mg per day. Motrin comes in tablet form and is taken orally. Motrin should be
avoided if there is active GI bleeding or if a ulcer is present. The patients pain should be
evaluated prior to administration of the medicine and again 1 hour later (Deglin and Vallerand,
2007). Prior to administration of the medicine DS reported her pain level at a 7 from 1-10. One
hour later her pain level went down to a 3 but she also took two tablets of Percocet when she
took the Motrin.
Percocet is an opioid analgesic. It binds to opiate receptors in the CNS which alter the
perception and response to pain while producing CNS depression. It is used for moderate to
severe pain, usually greater than 5 on a scale from 1-10. The patient’s blood pressure, pulse, and
reparation rate should be check before giving the medication and periodically during
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administration. The patient’s pain level should also be assessed before giving the medication
and 1 hour after. If the patient begins to develop respiratory depression, Narcan can be given.
Narcan is the antidote for Percocet and will increase the patient’s respiratory rate if the patient
was suffering from respiratory depression from the medication (Deglin and Vallerand, 2007).
Before this medication was given DS reported her pain level as a 7, an hour later her pain level
went down to a 3.
Evidence of Care Planning
Nursing
Diagnosis:
Risk for infection related to caesarean section incision.
Goal:
The patient will not develop an infection during her hospital stay.
Interventions:
1. Intervention: Asses patient’s temperature q8h.
Rationale: A temperature over 100.4 F may indicate an infection (Davidson
et al., 2008).
2. Intervention: Inspect the incision for abnormal drainage or odor q8h.
Rationale: If infected, the incision may have a yellowish-green discharge
and/or a foul odor (Craven and Hirnle, 2009).
3. Intervention: Teach proper hand washing to the patient as needed.
Rationale: Hand washing is the most important means to prevent infection
(Craven and Hirnle, 2009).
4. Intervention: Administer prophylactic antibiotics as ordered.
Rationale: Prophylactic antibiotics decrease the incidence of infection after
a caesarean section (Holcberg, Sheiner, and Schneid-Kofman, 2005)
Evaluation of
Goal:
During the shift the patient did not develop an infection. She showed no signs
or symptoms of an infection and her incision clean, dry, and did not have any
drainage.
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Nursing
Diagnosis:
Risk for impaired parenting related to history of postpartum depression.
Goal:
The patient will demonstrate increased attachment behaviors during her
hospital stay, and learn the sign and symptoms of postpartum depression and
when/how to find help.
Interventions:
1. Intervention: Provide the mother with uninterrupted sleep periods of at
least two hours during the day and four hours at night.
Rationale: There is a strong association of uninterrupted sleep and
postpartum depression and the finding that severe fatigue is an excellent
predictor of postpartum depression (Davidson et al., 2008).
2. Intervention: Encourage the mother to participate in skin-to-skin contact
and holding of the baby (kangaroo care).
Rationale: Close contact is beneficial to the bonding process (Davidson et
al., 2008).
3. Intervention: Evaluate the patient’s support system and encourage her to
ask for help as needed.
Rationale: A proper support system can help to alleviate feelings of being
overwhelmed, which can lead to postpartum depression (Davidson et al.,
2008).
4. Intervention: Encourage the patient to talk to their primary care provider or
a psychiatrist if feelings of depression last longer than two weeks of if
thoughts of injuring themselves or the infant develop.
Rationale: Psychotherapeutic interventions are an effective way to treat
postpartum depression (Gorman, O’Hara, and Stuart 2003).
Evaluation of
Goal:
During the shift the patient demonstrated appropriate attachment and bonding
behaviors with the baby. The patient also described the signs and symptoms
of postpartum depression and what to do if they appear.
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Nursing
Diagnosis:
Readiness for Enhanced Knowledge r/t circumcision AEB the parent’s interest
in learning about circumcision and the care thereafter.
Goal:
Educate the parents efficiently so that the parents can make a decision about
circumcision by the end of our shift and if they choose to have their son
circumcised, explain the care that will need done afterwards. Parents will
demonstrate proper ways in which to care for a circumcision by the end of our
shift.
Interventions:
1. Intervention: Educate the parents on the potential risks and benefits of
circumcision
Rationale: To ensure informed and educated consent, the parents should
be informed about the possible long-term effects and risks of circumcision and
non-circumcision (Moreno, Furtner, & Rivara, 2010).
2. Intervention: Demonstrate how to care for a circumcision and observe the
parents performing proper circumcision care.
Rationale: Observance of skills is an effective and accurate way to
measure the understanding of nursing instructions (Davidson et al., 2008).
3. Intervention: Instruct the patient on how to identify signs of infection and
hemorrhage and when to call the healthcare provider.
Rationale: Infection and hemorrhage are complications of circumcision
that can be very harmful to the baby if not caught and treated early (Davidson
et al., 2008).
4. Intervention: Instruct the patient on how and why to teach other
people caring for the new baby boy circumcision care and observe her
teaching a family member proper circumcision care.
Rationale: Being able to teach another person how to perform a skill
demonstrates that the skill has been mastered (Craven & Hirnle, 2009).
Evaluation of
Goal:
By the end of our shift, the parents made an educated decision to get their son
circumcised. After the circumcision, I observed the mother demonstrating
proper circumcision care to her mother (the baby’s grandmother) because she
would be caring for the baby for a couple weeks along with the mother and
father. The mother applied petroleum jelly to the penis and put the diaper on
securely over the penis. I also heard the mother explain what the signs of
infection were such as redness, discharge, swelling, or decreased urine.
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Nursing
Diagnosis:
Risk for imbalanced nutrition: less than body requirements r/t psychological
factors AEB a history of anorexia.
Goal:
Educate the patient on the importance of proper prenatal nutrition and provide
her with relevant and helpful resources to help her achieve healthy dietary and
weight loss habits during her hospital stay.
Interventions:
1. Intervention: Explain the importance and benefits of adequate caloric and
nutritional intake during the prenatal period and encourage her to ask about
any questions or concerns she may have.
Rationale: Accurate and appropriate education about the effects of nutrition
may provide a buffer to the negative messages conveyed by the woman about
foods and mealtimes (James, 2001).
2. Intervention: Refer the patient to a dietician to help achieve healthy weight
loss and proper nutrition.
Rationale: Education and individualized meal plans can help a woman
manage her dietary intake while maintaining a sense of control (Davidson et
al., 2008).
3. Intervention: Explain the effects of the mother’s poor nutrition on her
child.
Rationale: Parents’ eating habits and dietary practices will eventually be
reflected in the diet of their child(ren) (Craven & Hirnle, 2009).
4. Intervention: Educate the mother and other family members (father,
grandmother) about how to recognize a relapse of anorexia and how, where,
and when to seek help.
Rationale: Eating disorder behaviors decrease during pregnancy, but the
risk of relapse and the risk of postpartum depression increase following
pregnancy (James, 2001).
Evaluation of
Goal:
By the time the patient was discharged, she was able to explain proper
postpartum nutrition and weight loss to us. She had a good appetite
during her hospital stay and ate at least 75% of all meals. She also met
with a dietician.
Aspects Not Considered
Although these diagnoses are very relevant for our patient and her new baby boy, they are
not inclusive. The mother had some other things in her history and assessment that were not
touched on by the four diagnoses we chose. For example, D.S. was experiencing pain due to the
C-section and at one point, she was experiencing pain up to a level seven. We could have
focused on the managing the patient’s pain as a nursing diagnosis. D.S. also mentioned to us that
she was “looking into WIC”. Because of this, we could have chosen a nursing diagnosis
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focusing on educating the mother and father about how to ensure that their family had enough
nutritious food available to them. For example, we could have referred them to some
government and local programs available for families needing a little help regarding food. One
very important aspect of D.S.’s prenatal history that worried me is the fact that she has a sister
who had a child with Down syndrome, yet still refused the triple screen. Because of this, I think
another possible diagnosis we could have focused on was one in which we really tried to educate
her on the genetics of Down syndrome and how the triple screen could help determine if there
was a genetic mutation if D.S. wanted to have another child. I think we could have also focused
on educating her on the risks of having another child due to her advanced maternal age. Another
diagnosis we could have used was one pertaining to who would be helping the mother care for
the baby when they were both discharged. It is very important for a mother to have support from
her family with caring for a newborn. We actually did discover that the father and grandmother
of the baby would be taking off some time from work to help D.S. care for her new child as well
as her other three year old son, so that was very encouraging to hear the great support system
D.S. had. One last aspect of D.S.’s history that could have been addressed by a nursing
diagnosis is the fact that she has acquired a sexually transmitted disease (STD) in the past and
also a urinary tract infection (UTI) while she was pregnancy. We could have educated her on
how to protect herself from STDs and UTIs and also the effects they have on the fetus, if D.S.
would become pregnancy again. Although these possible diagnoses topics along with the four
main diagnoses we chose are very relevant to this patient and the newborn, we again want to
reiterate that they are not all-encompassing. Instead, they serve as a good overview of actual or
potential problems and their solutions, helping us to gain practice in the care planning of
maternal-newborn nursing.
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Concerns for Ongoing Care
Although D.S. and her new baby boy were in good health while at the hospital, there are
a couple areas in which ongoing care is concerned. For example, D.S. is not exhibiting any signs
of PPD or anorexia, but it is important to keep monitoring for signs and symptoms of these
psychological disorders. Also, it is important to encourage D.S. and her husband to seek genetic
counseling if they decide to try and conceive another child due to D.S.’s advanced maternal age
and family history of genetic disorder. Since D.S. and her husband were “looking into WIC”, it
is important to ensure that they have the resources to learn more about local and government
programs that could help them with their nutritional needs. As D.S. and her baby are discharged,
it is essential to keep managing D.S.’s pain. Also, it is important to keep monitoring her incision
as well as her baby’s circumcision to detect any signs and symptoms of possible infections.
Another concern going forward is paternal postpartum depression. Although D.S.’s
husband showed no signs of depression and no evidence of a history of depression was noted, it
is a phenomenon that is watched more carefully. Postpartum depression in both parents is a
major concern. One study (Zelkowits and Milet in 2001) showed the almost 25% of male
partners reported signs of depression when they were in a relationship with a female diagnosed
with postpartum depression (Goodman, 2004). Both parents suffering from PPD could have
devastating and lasting effects on the family.
Conclusion
D.S seemed to have everything in order during our clinical shift. She was bonding and
providing care to the baby and had a good support group between her husband and mother. The
major concern for D.S. is that she would have a reoccurrence of postpartum depression (PPD).
Hopefully between the education provided to her about PPD and her past diagnosis of PPD she
Running head: D.S. CASE STUDY
19
will know what signs and symptoms to be aware of and be able to get help as soon as possible. It
is encouraging that she was not ignoring the problem and was getting some type of help with
depression before (She was taking cymbalta which is an antidepressant) and hopefully she will
do it again should the need arise.
With the help of many useful sources, we have gotten a better understanding of the
dynamics of what affects pregnancy, the prenatal stage, and the postpartum period. Through
learning about D.S. and analyzing her medical information, we were really able to learn more
about the nursing specialty of maternal-newborn nursing.
Running head: D.S. CASE STUDY
20
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