Preeclampsia-Eclampsia SKINNY Reasoning

Preeclampsia-Eclampsia SKINNY Reasoning Dana Myers, 40 years old Primary Concept Intracranial Regulation Interrelated Concepts (In order of emphasis) • Perfusion • Reproduction • Clinical Judgment • Patient Education 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%  SKINNY Reasoning Part I: Recognizing RELEVANT Clinical Data 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: RELEVANT Data from Social History: Clinical Significance: 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: