Running head: PRIMARY CARE PLAN
1
Primary Care Plan
Rebecca Clopp
Arizona State University
PRIMARY CARE PLAN
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Patient Summary and Pathophysiology
Patient B.D. is a 19 year old single female whose primary language is English. The father
of the baby is her 22 year old boyfriend, and they have been together for two years. They are
both currently in scrub tech school. The patient is a G1P0101, and is currently 35 weeks
gestation. Her estimated date of conception is 3/1/12, and her estimated due date is 12/19/12. The
patient is currently admitted for severe preeclampsia and breech presentation. B.D. is on
AHCCCS, and received full prenatal care including vitamins and classes. The patient is joined by
her boyfriend, mother, sisters, friends, and boyfriend’s parents. She currently lives with her
mother, and plans to bring the baby back there. The patient is allergic to Seritaline HCL. The
patient is currently on 2g/hr Magnesium Sulfate, 600mg of Propanolol, and 800mg of Percocet.
She is on bed rest with bathroom privileges, and NPO because she is scheduled for a C-section.
The patient and her boyfriend are having some difficulty getting along, and dealing with the
adaptation to parenthood. The patient’s sister has had two previous pregnancies with severe
preeclampsia and her last one progressed to eclampsia. She was told to never get pregnant again
due to the health risk. Her family has a history of preeclampsia, but no family cases have been as
severe as her and her sisters. The patient has a history of depression and anxiety, but doesn’t feel
the need to be medicated as she feels the medications are not helpful. The patient has also
witnessed a C-section before, and although states she isn’t anxious, her body language suggests
otherwise.
Preeclampsia is a pregnancy-specific condition in which hypertension and proteinuria
develop after 20 weeks of gestation in a previously normotensive woman (Dix, 2012). The exact
cause of preeclampsia is unknown, but some possible causes include genetic predisposition, diet,
blood vessel problems, and autoimmune disorders. Much of the pathophysiology of preeclampsia
PRIMARY CARE PLAN
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is related to abnormal placentation (Uzan et al, 2011). During implantation the fetal cells
normally adopt certain attributes of maternal endothelium that usually replace, but in
preeclampsia this process is unsuccessful (Uzan et al, 2011). This causes inhibition of maternal
synthesis of the nitric oxide pathway which impacts control of vascular tone. Oxidative stress
and endothelial dysfunction lead to vascular hyperpermeability, thrombophilia, and hypertension
(Uzan et al, 2011). In all, preeclampsia is due to maternal peripheral vasoconstriction which is a
result of overcompensation for decreased arterial uterine flow.
Nursing 421 Priority Care Plan
I.
Client Data Base:
Gestational Age:
EDC:
35w
_3_/ _1_/ _12_
G ravida Parity
Allergies:
G 1 P 0111
Seritaline HCL
Current Weight:
Marital Status:
205
Single (boyfriend)
Pre-Pregnancy Wt:
Support Person:
142
FOB, Mom
Year
Gestational
Age
2011
10w
2012
2012
34.5w
35w
Wt
Gender
Delivery
Mode
Obstetrical
Problems
-
-
Spontaneous
Abortion
No D/C noted
6.02 lbs
-
-
Preeclampsia
F
C/S
Breech Presentation
Neonatal Problems
Cyanosis, Retractions,
Grunting, and low
Blood Sugar
History of Present Illness (HPI)/ Reason for admission/ Diagnosis (include onset of presenting symptom):
_____Patient was admitted due to severe preeclampsia and a blood pressure reading of
198/105 on admission with a proteinuria of 6.4g. Patient was feeling extreme fatigue and
tachycardia when she decided to take her own blood pressure, which was 182/98. Breech
presentation was noted on 11/13/12 at 0100.
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Current Medications:
Medication
Dosa
ge
10g/
dose
Frequency
Route
Major Side Effects
Major Nursing Interventions
2g/hr
IV
Drowsiness, decreased
respiratory rate, arrhythmias,
bradycardia, hypotension,
diarrhea, muscle weakness,
flushing, sweating
Percocet
800
mg/
day
2 tabs PRN
PO
Pitocen
20u/
1000
ml
PRN
dependent
on
postpartum
bleeding
IV
Cytotec
1000
mg/
dose
1 dose/day
Rectal
Confusion, sedation, dizziness,
hallucinations, blurred vision,
respiratory depression,
constipation, dry mouth
Coma, seizures, fetal
intracranial hemorrhage,
increased uterine motility,
painful contractions,
abruption placentae,
decreased uterine blood flow
Diarrhea, headache, stomach
pain, constipation, vomiting,
bloody or black stool
Monitor HR, BP, RR, and ECG
frequently.
Monitor DTR, clonus, and
neurological status frequently.
Monitor urine output, proteinuria,
and serum magnesium.
Monitor fetus for decreased FHR
Assess BP, HR, and RR before and
after administration.
Assess bowel function routinely
Magnesium
Sulfate
Monitor maternal HR, and BP
Monitor uterine contractions
Assess routinely for epigastric or
abdominal pain and for blood in
the stool
Prenatal Labs:
Lab
HgB/ HCT
Result
11.7/35
Lab
Gonorrhea
Result
-
RPR/ Syphillis
HIV
Hepatitis B
Nonreactive
Chlamydia
Blood Type/ Rh Status
Ultrasound
Other:
_AST/ALT_______
Other:
______________
Result
-
O+
+
Lab
Diabetes Screen:
1 hour __
2 hour __
Rubella
AFP/ Genetic Screening
Group Beta Strep
42/45
IU/L
Other:
Genital Herpes
+
+
-
Past Medical History (PMH):
Medical Problems
Generalized Anxiety/Depression
Surgery/ Year
n/a
Home Medications/ Dosage/ Indication
Pt states medications do not help, and therefor feels
she does not need medications.
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Social History: (Include past and present for substance use)
Item
Tobacco:
Alcohol:
Other Substances:
marijuana
Yes
X
No
Type
cigarettes
Frequency
daily
Last Encounter/ Use
1 year ago
marijuana
occasionaly
2010
Pre-surgical
nothing PO
-------------------------
(last PO):24 hrs ago
X
X
Exercise:
X
Abuse:
 Sexual ____
 Domestic ____
 Verbal ____
Special Diet Needs
X
X
Initial Vaginal Examination:
Cervix:
Dilatation 0 Effacement_50%_ Station_-3_ Presentation_Breech_
Time: _0700_
Membranes:
Intact: Yes_X_ No____ ROM____ Date____ Time____ Color of fluid_____________
Intrapartum Period:
Pain Management:
Delivery Type:
(If Cesarean Section, specify reason for
this)
Length of Labor:
Intrapartum Medications:
(ie ABX, Pitocin, Magnesium Sulfate,
etc)
C-Section
Patient had severe preeclampsia,
and infant presentation is breech.
20 minutes
Magnesium Sulfate, Ancef, Spinal
Block, Epinephrine, Lactated
Ringers
Newborn Information:
Weight:
Head:
1 Min APGAR:
Nutrition
Skin to Skin/ Kangaroo
Care
_2730_ gms _6.02_ lbs
_33_ cm
8
Breast ___ Bottle _X_
Yes _X_ No ___
Length:
Meds Given:
Vitamin K
Erythromycin
5 Min APGAR:
Nursed Immediately
Other:
__49__cm __19.3__ in
Yes _X_ No ___
Yes _X_ No ___
9
Yes ___ No _X_
Chest 30.5 cm
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Care Plan B.D.
Nursing Diagnosis:
1. Risk for hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome)
related to glomerular function impairment, decreased cardiac output and decreased
venous return secondary to severe preeclampsia as evidenced by elevated AST/ALT
levels, +2 edema, decreased respiratory rate, elevated blood pressure, and proteinuria.
a. Rationale: HELLP syndrome is a life threatening condition to the mother and the
fetus. Due to the fact that my patient had been on magnesium sulfate for two
days, and still was considered severely preeclamptic as well as had elevated liver
enzymes I felt that this was the highest priority as far as safety of my patient and
fetus.
2. Altered uteroplacental tissue perfusion related to maternal peripheral vasoconstriction
and interruption of blood flow as evidenced by premature delivery and changes in fetal
activity and heart rate.
3. Risk for hemorrhage and infection related to soft tissue injury or lacerations from
cesarean delivery.
4. Fetal injury related to traumatic gestation and delivery secondary to severe
preeclampsia and breech presentation as evidenced by hypoxemia, grunting,
retractions, bruising, and flaccid limbs.
Expected Outcomes:
EO #1 The patient will remain normotensive after delivery of baby.
EO #2 The patient will have absent or decreased episodes of bradypnea.
PRIMARY CARE PLAN
Interventions
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Rationale
Monitor/Assess
1. Monitor and graph blood
pressure and pulse.
1. Establishing baseline data is useful as a basis for
evaluating effectiveness of treatment (Herdman,
2008).
2. Assess for CNS involvement and
note changes in level of
consciousness.
2. Vasoconstriction and vasospasms of cerebral
blood vessels reduce oxygen consumption and may
result in cerebral ischemia (Dix, 2012). Indications of
cerebral ischemia include headache, decreased
level of consciousness, and visual disturbances.
3. Assess deep tendon reflexes,
ankle clonus, decreased
respirations, epigastric pain, and
oliguria.
3. Hyperactivity of deep tendon reflexes 3+/4+,
+1/+2 ankle clonus, respiratory rate <14, epigastric
pain, and voiding less than 50cc/hr are indicators of
an impending seizure (Vorvick, 2012). Assessing
these signs are important in monitoring if the
preeclampsia is progressing and if seizure
precautions need to be implemented.
4. Monitor platelet count, red blood
cell count, liver enzymes, and
bilirubin.
4. Low platelet and red blood cell count along with
elevated liver enzymes and bilirubin may indicate
the presence of HELLP syndrome, which is a life
threatening event, and an emergency cesarean
delivery is needed. Also low platelet count,
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thrombocytopenia, indicates the need for general
anesthesia because procedures requiring a needle
could result in excessive bleeding (Vorvick, 2012).
Therapeutic
1. Place the patient on strict bed
rest, and encourage lateral
position.
1. Lateral recumbent position decreases pressure
on the vena cava, increasing venous return and
circulatory volume. This enhances placental and
renal perfusion, reduces adrenal activity, lowers
blood pressure, and reduces edema (Herdman,
2008).
2. Keep the patient’s room dark and
quiet, limit visitors, implement
cluster care, and promote rest.
2. Reducing environmental factors may help to
reduce the likelihood of seizures (Herdman, 2008).
3. Administer MgSO4 and
propranolol as indicated by
medication orders.
4. Avoid traumatizing the liver by
abdominal palpation.
3. Magnesium sulfate is a CNS depressant used to
prevent seizures, lower blood pressure, and
decrease uterine stimulation. Propranolol is a beta
blocker used to decrease blood pressure. Used in
combination these drugs may reduce the severity of
pregnancy induced hypertension, and keep
preeclampsia from progressing into eclampsia or
HELLP syndrome (Vorvick, 2012).
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4. “A sudden increase in intra-abdominal pressure
could lead to rupture of a hematoma that could
result in internal bleeding and hypovolemic shock”
(Vorvick, 2012)
Interventions
Rationale
Educate
1. Educate the patient on the signs
and symptoms indicating
worsening of condition, and
instruct the patient when notify
healthcare provider.
1. This helps to ensure the patient seeks timely
treatment and therefore interventions to decrease
worsening of the preeclampsia are implemented
earlier which in turn may lead to better outcomes
(Dix, 2012).
2. Provide information about
preeclampsia and the
implications for the patient and
fetus, as well as the rationale for
interventions, procedures, and
tests as needed.
2. Includes and involves patient in treatment plan,
and allows patient to make an informed decision.
“Receiving information can promote understanding
and reduce fear” (Herdman, 2008).
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Referral
1. Refer patient to home monitoring 1. Monitoring blood pressure daily confirms a
and follow-up care before
normotensive state, or helps to promote early
discharge.
intervention. Adequate surveillance by the patient
allows for possible outpatient care. Empowering the
patient to participate in their care helps to reduce
anxiety and fear upon discharge (Dix, 2012).
2. Adequate protein, calcium, folic acid, zinc, and
2. Refer patient to a dietician and
fluids can enhance renal perfusion, and limiting salt
recommend a nutritious balanced intake can help to lesson edema (Dix, 2012).
diet
Evaluation: The patient had a sudden drop in her blood pressure after her spinal block and was
given 10ml of epinephrine. The patient was on magnesium sulfate 2g/hr throughout her
delivery and postpartum, and after the epinephrine was administered her blood pressure
normalized. But around two hours after her spinal block was administered, her blood pressures
increased tremendously. The patient was not having bradypynea after delivery, but she also
was not normotensive.
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References
Dix, D. (2012). Hypertensive Disorders in Pregnancy In Lowdermilk et al. Maternal and
Women’s Health Care Hypertensive Disorders in Pregnancy. Mosby: Elsevier.
Herdman, T. H., & North American Nursing Diagnosis Association. (2008). NANDA-I nursing
diagnoses: Definitions & classification, 2009-2011. Oxford: Wiley-Blackwell.
Vorvick, L. (2012). HELLP Syndrome. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001892/
Uzan, J., Carbonnel M., Piconne O., Asmar R., Ayoubi J.M. (2011). Vascular Health Risk
Management. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3148420/citedby/