Week 5 Case Study ALL ANSWERS 100% CORRECT FALL-2021 SOLUTION GUARANTEED GRADE A+

Luella Jones, 25 years old Primary Concept Perfusion Interrelated Concepts (In order of emphasis) • Reproduction • Clinical Judgment 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%  RAPID Reasoning Case Study History of Present Problem: Luella Jones is a 25-year-old female patient G1P0 who is currently 40 3/7 weeks gestation. She is admitted to the hospital to be induced for being post-date. She is positive for Group Beta streptococcus and receiving IV antibiotics per protocol. She is 65 inches (162.5 cm). Her pre-pregnancy weight was 115 pounds (52.3 kg). She gained 15 pounds (6.8 kg) during this pregnancy. She just had spontaneous rupture of membranes with a moderate amount of thick meconium fluid. The nurse performed a vaginal check, and her cervix is dilated to 4 cm, 80 percent effaced and -1 station. Pitocin is infusing at 6 mU/minute intravenously. Personal/Social History: Luella lives alone and is no longer involved with the father of her baby. Her family support is limited to her older sister. She smokes one pack of cigarettes a day and has not had a job for over a year and states money is tight. She admits to not eating very healthy during the pregnancy because it is easier to grab chips and pop than cook. She missed a few of her prenatal visits due to transportation issues and did not attend any prenatal classes. Her sister is present as her support person during labor and delivery. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT Data from Present Problem: Clinical Significance: • Gained only 15 lbs with a BMI of 19.7 • I’m not sure if the nurse performed her vaginal check after the rupture of membranes or not BUT if she did… • 4 cm dilated, 80% effaced, -1 station • Meconium = baby poop • (+) GBS • With a BMI of 19.7 before pregnancy, Luella should have gained between 25-35 lbs during her pregnancy w/ an average of gaining 1 lb/day during her 2nd and 3rd trimester she has only gained 15 lbs indicating that the baby may be malnourished and have a lower birth weight than normal once it is delivered. • Luella is at higher risk for infections and vaginal exams should be kept to a minimum to prevent infections • Luella’s bishop scoring is about a 3 if the cervix is soft and the position is anterior • Mucous plug should keep meconium in amniotic fluid, but stress can cause mucous plug to rupture floats around in amniotic fluid where baby can swallow it and get into which is really bad because that means the baby is probably really stressed  this can lead to meconium aspiration pneumonia and need to suction if delivery happened • Increased risked for sepsis RELEVANT Data from Social History: Clinical Significance: • Luella’s support is limited to her sister • Luella does not have a reliable means of transportation • Luella smokes a pack of cigarettes a day • Luella stated money was tight and she has not had a job for over a year • She has not gone to a couple of her prenatal visits • Having a solid support system is key in providing a safe home for the baby as well as making sure Luella is faring well with her new role (both psychologically and physically). • This is concerning because it is important, she show up for her post-pregnancy checkups as well as any pediatric appointments that are coming up in the near future which help ensure the wellbeing of the infant if Luella were to have any concerns. • Smoking while pregnant can have teratogenic effects putting her infant at a high risk for abnormalities secondhand smoking can contribute to SIDs • Not being a stable economic situation puts the infant at risk for not receiving the proper nutrition it needs to grow and mature • This is concerning because this might be a sign of baby/mom mal- attachment because she is not concerned about the well-being of her child Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 99.9 F/37.7 C (oral) Provoking/Palliative: Uterine contractions P: 90 (regular) Quality: Severe cramping R: 18 (regular) Region/Radiation: Low pelvis BP: 118/68 Severity: 5/10 O2 sat: 98 % RA Timing: With uterine contractions What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: • Lower abdominal pain • 99.9 • Vital signs are completely in line with pain rating • contractions are usually higher up but someone can have all back labor and it completely varies • On the higher range infections • But if pulse were to go up that’s also a sign of infection Fetal Monitoring Strip: Interpretation: • Fetus is experiencing late decels with the onset of contractions • No accelerations • HR ~140 is normal • Variability is minimal • No accelerations • V shaped decelerations variable decelerations (not lasting as long) VEAL CHOP • Category indeterminate (definitely not normal, but enough to be concerned about, keep monitoring) • **normal after getting n epidural, blood pressure might drop but should remain calm and change position to see if it improves Clinical Significance: • CHORD COMPRESSIONIndicates fetal hypoxia (poor perfusion) change position of patient to left lateral side (lying) to help with perfusion to baby • No accelerations keep monitoring Current Assessment: GENERAL APPEARANCE: Calm and appears to be resting between contractions. Using breathing techniques during contractions appropriately RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, brisk cap refill, 1+ bilateral pedal edema NEURO: Alert and oriented to person, place, time, and situation (x4) Maternal/Fetal FHT’s: 140s regular Variability: See monitoring strip to address Accelerations: See monitoring strip to address Decelerations: See monitoring strip to address Contractions: Yes Frequency: Every 3-4 minutes Duration: 60-70 seconds Intensity: Moderate to palpation What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse?