Case Study 2 - Labor-Vaginal Delivery, UNFOLDING Reasoning, Anne Jones, 17 years old

Labor-Vaginal Delivery UNFOLDING Reasoning Anne Jones, 17 years old Primary Concept Pain Interrelated Concepts (In order of emphasis) 1. Perfusion 2. Stress 3. Anxiety 4. Reproduction 5. Clinical Judgment 6. Communication 7. Collaboration NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment • Management of Care 17-23% • Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12% Psychosocial Integrity 6-12% Physiological Integrity • Basic Care and Comfort 6-12% • Pharmacological and Parenteral Therapies 12-18% • Reduction of Risk Potential 9-15% • Physiological Adaptation 11-17% Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. History of Present Problem: Anne is a 17-year-old, gravida 1 para 0 who is 39 weeks gestation and admitted to the labor room for observation at 1200. She began having contractions three hours ago at 8 to 10-minute intervals with each contraction lasting 30 seconds. She states her pain is 3/10. Her membranes are intact. On admission, a vaginal exam indicates cervical dilation is 1 cm, 80% effacement, and 0 station. After two hours of observation, her cervix is 2-3 cm/ 80% effacement/0 station and contractions are now 4- 5 minutes apart, lasting 60-70 seconds and pain remains 3/10. Fetal lie is longitudinal with a cephalic presentation. You have her prenatal records from her visits to the office. She is Group Beta Strep (GBS) positive and received antibiotics at 36 weeks. Her blood type is B-. Personal/Social History: Anne’s mother is with her. Anne is not married and the father of the baby is not involved. She appears to be relaxed although she states she is a bit nervous. She wants a natural non-medicated birth and her mother will help coach her. She plans on breastfeeding for “awhile”. She attended childbirth preparation classes with her mother. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: - Cervix 2-3 cm dilated , contractions 4 - 5 minutes apart lasting 60-70 seconds - Blood type B- - Onset of labor - The negative mother should receive a dose of RhoGAM within 72 hours after given birth to an Rh- positive newborn. The nurse should inform Anne the reason behind receiving RhoGAM if Anne’s baby blood type is positive. She should inform Anne that receiving this shot in the deltoid prevents sensitization to Rhpositive erythrocytes that may have entered her bloodstream when the newborn was born. She should have received the first dose at 28 weeks since this is her first pregnancy RELEVANT Data from Social History: Clinical Significance: - Anne is going to be a 17 year old single mother - Her mother is her support system - She plans on breastfeeding - She is having an unmedicated birth The nurse must assess Anne’s development and educational level and her support system to best provide care for her. In Anne’s case, her only support system is her mother because the father is not involved. The nurse should also maintain a nonjudgmental attitude and assist the single mother to successfully achieve the psychological tasks of pregnancy Anne is placed on a fetal monitor and the nurse collects the following strip: Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. Fetal Heart Rate Strip Assessment: Fetal Monitoring Strip: Interpretation: Early decelerations Clinical Significance: They begin early before the peak of the contraction. Early decelerations can happen when the baby’s head is compressed. This often happens during later stages of labor as the baby is descending through the birth canal. They may also occur during early labor if the baby is premature or in a breech position Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 98.6 F/37.0 C (oral) Provoking/Palliative: Began 3 hours ago