NUR1211C: Preeclampsia-Eclampsia RAPID Reasoning,Dana Myers, 40 years old (Answered)

Preeclampsia-Eclampsia RAPID Reasoning Dana Myers, 40 years old Primary Concept Intracranial Regulation Interrelated Concepts (In order of emphasis) 1. Perfusion 2. Reproduction 3. Clinical Judgment © 2016 Keith Rischer/www.KeithRN.com RAPID Reasoning Case Study: STUDENT Preeclampsia-Eclampsia History of Present Problem: Dana Myers is a 40-year-old woman, G-3 P-2 who is 34 weeks gestation. Her health care provider has been monitoring her weekly because her blood pressure has been increasing the past month and is currently 146/88. Last week she had 1+ non-pitting edema of both lower extremities (BLE) and her urine was negative for protein. Today during her clinic visit, Dana’s BP was 168/90. She had 2+ proteinuria and 3+ pitting edema BLE. She also complained of a mild headache in the center of her forehead, and seeing “spots.” Fetal heart tones via Doppler are 136/minute in the lower left quadrant. Abdominal measurement from pubic bone to top of fundus is 31 cm. The primary care provider was concerned and Dana has been admitted to the community hospital labor and delivery unit to be evaluated for severe preeclampsia. You are the admitting nurse responsible for her care. Personal/Social History: Dana has two children, ages two and four. She is married and both she and her husband are excited to have another baby, but have been concerned about this pregnancy. Dana’s previous two pregnancies were healthy, without incident, resulting in the vaginal births of a boy, then a girl. Dana’s parents live in the same town and are supportive. Dana works part-time teaching English at the local community college. Her husband is an engineer who works full time and is occasionally out of town for work. Dana is generally healthy, without any chronic illnesses. She does not smoke or use recreational drugs. She reports drinking socially but refrains while pregnant. What data from the histories are RELEVANT and has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: Increasing blood pressure. +2 proteinuria Pitting edema BLE Mild headache in the center of forehead and seeing spots. These are all manifestations of preeclampsia. RELEVANT Data from Social History: Clinical Significance: Two children ages 2 and 4. Married. Parents live in same town. Part-time teaching English. Husband engineer. Dana already has two younger children, which could be stressful with being pregnant and having complications. With Dana being married and having her parents living in the same town, shows that she has a good support system. Dana works part-time and her husband is an engineer, so they are financially stable. Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 98.4 F/36.9 C (oral) Provoking/Palliative: None P: 84 (regular) Quality: Stabbing/throbbing R: 20 (regular) Region/Radiation: Eyes, forehead BP: 164/98 Severity: 5/10 O2 sat: 95% room air Timing: Constant, unrelieved by acetaminophen What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: BP:164/98 Constant, stabbing, throbbing pain in eyes and forehead and is unrelieved by acetaminophen. High blood pressure is related to preeclampsia. Headaches and vision changes can be associated with CNS irritation or could indicate cerebral edema. Website. “Preeclampsia - Signs-And-Symptoms.” Preeclampsia Foundation - Helping Save Mothers and Babies from Illness and Death Due to Preeclampsia, Current Assessment: GENERAL APPEARANCE: Appears uncomfortable RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort CARDIAC: Pink, warm/dry, 3+ non-pitting edema of BLEs with generalized edema of hands, face, and sacrum, heart sounds regular with no abnormal beats, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert and oriented to person, place, time, and situation (x4). Reflexes are brisk with no clonus, c/o headache and continues to see “spots” GI: Abdomen soft/non-tender, slight epigastric discomfort, bowel sounds audible per auscultation in all four quadrants, no contractions palpated, uterus soft. GU: Voiding without difficulty, urine clear/yellow, urine 2+ by dipstick. SKIN: Skin integrity intact What assessment data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: 3+ non-pitting edema of BLEs Generalized edema of hands, face, and sacrum. Slight epigastric discomfort. Urine 2+ by dipstick. Due to fluid retention in the body’s tissues. Epigastric gastric pain could be related to many different factors. It is also a manifestation of preeclampsia. Non-stress Test What results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Results: Clinical Significance: The non-stress test is non- reactive. Fetal heart rate baseline 130, with minimum variability and no accelerations. No decelerations are noted. Non-stress test non-reactive indicates baby did not make the minimum number of movements for the time period. Baby could be sleeping. Fetal heart rate is normal with minimal fluctuation in heart rate. Lab Results: Complete Blood Count (CBC:) Current: High/Low/WNL? Previous: WBC (4.5–11.0 mm 3) 5,000-15,000 14.8 WNL 14.5 Hgb (12–16 g/dL) Pregnancy: 11.5-14 11.3 Low 11.4 Platelets (150-450 x103/µl) 72 LOW 115 Neutrophil % (42–72) 70 WNL 68 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Hgb Platelets Hgb is low but not by much. Hgb need to be monitored to observe for a decreasing trend. Low platelet count could indicate HELLP syndrome. Worsening Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Previous: BUN: (7–25 mg/dl) Pregnant: (3-11mg/mL) 33 High 11 Creatinine: (0.6–1.2 mg/dL) Pregnant: 0.4-0.9 mg/mL 2.1 High 1.4 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: BUN Creatinine BUN and Creatinine are elevated. Higher creatinine levels usually indicate fluid volume deficit or renal involvement in preeclampsia. Manaj, Aferdita, et al. “The Impact of Preeclampsia in Pregnancy.” Journal of Prenatal Medicine, CIC Edizioni Internazionali, Jan. 2011, Worsening Liver Function Test (LFT:) Current: High/Low/WNL? Previous: Albumin (3.5–5.5 g/dL) 4.5 WNL 4.7 Total Bilirubin (0.1–1.0 mg/dL) 0.5 WNL 0.6 Alkaline Phosphatase male: 38–126 U/l female: 70–230 U/l 122 WNL 90 ALT (8–20 U/L) 20 WNL 18 AST (8–20 U/L) 18 WNL 20 LDH (90-156 units/L) 98 WNL 90 RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Alkaline phosphatase All labs are within normal limits. Alkaline phosphatase is increasing. Needs to be monitored. Could be related to HELLP syndrome. C. Delluc, N. Costedoat-Chalumeau, D. Saadoun, D. Vauthier- Brouzes, B. Wechsler, J.-C. Piette, Elevation of alkaline phosphatase in a pregnant patient with antiphospholipid syndrome: HELLP syndrome or not?, Rheumatology, Volume 47, Issue 4, April 2008, Pages 554–555, Urine Analysis (UA:) Current: WNL/Abnormal? Previous: PCR 4.3 Abnormal n/a What lab results are RELEVANT and must be recognized as clinically significant by the nurse?