Unfolding Clinical Reasoning Case Study: Postpartum Hemorrhage (PPH) Brenda Jackson, 22 years Old 100%Solved Assured A+.

Unfolding Clinical Reasoning Case Study: Postpartum Hemorrhage (PPH) Brenda Jackson, 22 years Old 100%Solved Assured A+. Primary Concept Perfusion Interrelated Concepts (In order of emphasis) 1. Clotting 2. Clinical Judgment 3. Patient Education 4. Communication 5. Collaboration Unfolding Clinical Reasoning Case Study: Postpartum Hemorrhage (PPH) Brenda Jackson, 22 years Old 100%Solved Assured A+. UNFOLDING Reasoning Case Study: Postpartum Hemorrhage (PPH) History of Present Problem: Brenda Jackson is a 22-year-old African American, G-1, now T-1 P -0 A- 0 L-1 who is Group B strep positive and was treated with four doses of penicillin G. She had a vaginal delivery over an intact perineum after 19 hours of labor at 39 weeks gestation. She has been clinically stable and is about to be transferred to the postpartum unit after a two-hour recovery period. Oxytocin 20 units in 1000 mL of Lactated Ringer’s is infusing at a fixed rate of 125 mL/hr in a 20 g. peripheral IV in her left hand. Type and screen done on admission, Hgb 12.6/Hct 38. Her last set of vital signs were:  T: 99.4 F/37.4 C  P: 95  R: 18  BP: 110/67. She has gotten up to void once and had 50 mL of blood-tinged urine. Her fundus is firm at the umbilicus, and has a small amount of dark red lochia. She is physically exhausted and has been anxious since delivery because her labor and delivery were harder than she ever expected. Personal/Social History: Brenda is an advanced nursing student in her final year. She is single and remains in a relationship with her boyfriend, who is also the father of her baby. She lives at home with her parents, who are supportive. What data from the histories are RELEVANT and have clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: Group B strep positive and was treated with four doses of penicillin G. She is a G-1, term 39-week gestational vaginal delivery P: 95 BP: 110/67. Group B streptococcus (GBS) is a type of bacterial infection that can be found in a pregnant woman’s vagina or rectum. This bacteria is normally found in the vagina and/or rectum of about 25% of all healthy, adult women. Women who test positive for GBS are said to be colonized. A mother can pass GBS to her baby during delivery. GBS affects about 1 in every 2,000 babies in the United States. Not every baby who is born to a mother who tests positive for GBS will become ill. Although GBS is rare in pregnant women, the outcome can be severe for the newborn. Physicians include testing as a routine part of prenatal care. She is a first-time parent, with a low-risk prenatal history, delivery without complications, and normal BUBBLE-HE assessment Though this HR is not 100, it is close enough that it must be recognized as a clinical RED FLAG. This is not an acceptable ambiguity! It may be due to post-delivery pain or a compensatory response to hypovolemia based on physiologic compensation to maintain cardiac output. Remember the patho equation CO=SVxHR! This is now very relevant to clinical practice! Though this is the first BP in this scenario, emphasize the importance of TRENDING all clinical data especially in the context of this scenario when the worst possible/most likely complication is post-partum hemorrhage. The BP as well as HR are ALWAYS RELEVANT! IMPORTANT POINT to emphasize: Pregnancy increases circulating volume by 40% at term. This increase will conceal blood loss by maintaining the BP longer. Blood pressure in the immediate postpartum period should be normal; any deviation should be reported. Increased blood pressure can indicate gestational hypertension. Decreased blood pressure can be related to orthostatic hypotension, shock, or dehydration (side effect of epidural anesthesia).  Loss of 1000= orthostatic tachycardia  Loss 0f 1500= resting tachycardia, orthostatic hypotension  Loss of 2500=resting hypotension  Loss of 2500= oliguria C-V collapse and obtunded. (CMQCC, 2015) RELEVANT Data from Social History: Clinical Significance: Advanced nursing student in her final year She is single who is still in with relationship with her boyfriend who is also the father of her baby. She still lives at home with her parents who are supportive. Nursing is a stressful major, as every student can testify! She will need support and a plan to successfully manage and balance the demands of a new baby and her college education. Because she is single, it is important to assess the degree of social as well as family support and to involve social services as needed. Since she has a supportive significant other, this will likely not be needed but must be noted by the nurse. Has adequate support from parents, and/or boyfriend. What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medication treats which condition? Draw lines to connect.) PMH: Home Meds: Pharm. Classification: Expected Outcome: G1-T1-P0-A0-L1 Prenatal vitamin (PVI) 1 tab PO daily Ferrous gluconate 325 mg PO daily 1. Vitamins 2. Iron supplement 1. Prevention of deficiency or replacement of essential vitamins 2. Treatment and prevention of iron deficiency in pregnancy Patient Care Begins: Brenda arrived in her room ten minutes ago. You were delayed by another mother who required pain medication, but the nursing assistant collected the first set of vital signs posted below. You introduce yourself, orient her to the room and unit, and begin your BUBBLE-HE assessment: What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: P: 105 (regular) This is a clinical RED FLAG. This is not acceptable ambiguity! It may be due to pain postdelivery or a compensatory response to hypovolemia based on physiologic compensation to maintain cardiac output. Remember the patho equation CO=SVxHR! This is now very relevant to clinical practice! TRENDing all relevant data, including vital signs, is an essential component of clinical reasoning. The heart rate remains elevated and increased from previous HR of 95. Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 99.9 F/37.6 C (oral) Provoking/Palliative: Vaginal delivery P: 105 (regular) Quality: Cramp R: 22 (regular) Region/Radiation: Lower abdomen BP: 110/75 Severity: 6/10 O2 sat: 98% room air Timing: Started one hour after delivery What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: P: 105 (regular) This is a clinical RED FLAG. This is not acceptable ambiguity! It may be due to pain postdelivery or a compensatory response to hypovolemia based on physiologic compensation to maintain cardiac output. Remember the patho equation CO=SVxHR! This is now very relevant to clinical practice! TRENDing all relevant data, including vital signs, is an essential component of clinical reasoning. The heart rate remains elevated and increased from previous HR of 95.