Antepartum Care Skinny Reasoning Case Study, Anne Jones 17 Years Old

Antepartum Care SKINNY Reasoning Anne Jones, 17 years old Primary Concept Reproduction Interrelated Concepts (In order of emphasis) 1. Nutrition 2. Patient Education 3. Stress 4. Coping 5. 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%  Part I: Recognizing RELEVANT Clinical Data History of Present Problem: Anne Jones is a 17-year-old Caucasian teenager who thinks she may be pregnant because she has missed two periods. Her last menstrual period, she thinks, was about one month ago. She states she had a little bit of spotting last week but didn’t have a “full period”. She complains of her breasts being tender, swollen, frequent urination, and nausea in the morning. This is her first office visit and she is not sure why she feels so crummy but suspects she might be pregnant. Her urine pregnancy test is positive. Her primary care provider orders a prenatal lab panel and a urinalysis. Personal/Social History: Anne is a senior in high school who stands on her feet while working at McDonalds after school. She drinks six colas daily, denies alcohol use, and does not smoke. She takes no medications except for occasional acetaminophen for headaches and ibuprofen for menstrual cramps. Anne is 5’4” (160 cm) and weighs about 105 lbs. (47.7 kg) according to Anne. A 24-hour recall nutrition history reveals a typical day’s diet: breakfast- pop tart and can of cola; Lunch- a slice of pizza, chocolate chip cookie, can of cola; Dinner- fried chicken, green beans, biscuit, can of cola; snacks, including cookies and can of cola. She broke up last week with her boyfriend, and he is not aware she might be pregnant. She wants to keep the baby but has not told her parents. 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: - Last menstrual period about a month ago & missed two periods - Some spotting last week, but didn’t have full period - Breast tenderness, swollen, frequent urination & nausea in the morning - States she feels “crummy” - Positive urine pregnancy test The signs she is experiencing are presumptive indications of pregnancy; amenorrhea, nausea, urinary frequency, breast tenderness & swollen. Patient states she feels “crummy” could indicate fatigue which is also a presumptive sign. (McKinney et al., 2018, pg. 221) The probable indication of pregnancy would be the positive urine pregnancy test. (McKinney et al., 2018, pg. 224) RELEVANT Data from Social History: Clinical Significance: - High school senior who stand on her feet while working at McDonalds after school. - She is 5’4” (160 cm) & weighs 105 lbs (47.7 kg) - Drinks 6 colas daily, breakfast (poptart & cola), lunch (slice of pizza, chocolate chip cookie & cola), dinner (fried chicken, green beans, biscuit, cola), snack (cookies & cola). - Broke up with her boyfriend & he doesn’t know she might be pregnant. Her parents aren’t aware she wants to keep the baby. - As a teenager, teen pregnancy is her to manage pregnancy and still being an adolescent, standing on her feet at work may cause edema in her legs. (McKinney et al., 2018, pg. 226 & 242) - Based on the height and weight her calculated BMI is 18.02 which is considered under weight. (McKinney et al., 2018, pg. 256) - At risk for gestational diabetes, can also put the fetus at risk for hypoglycemia because of the excessive glucose from the mother. (McKinney et al., 2018, pg. 552) Also the caffeine intake should be less than 200 mg/day during pregnancy. (McKinney et al., 2018, pg. 268) - She might not have the support from her parents, and isn’t sure how to tell them or her ex boyfriend about the pregnancy. Assisting the patient with emotional support when needed in the process. Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 98.6 F/37.0 C (oral) Provoking/Palliative: Breast tenderness P: 76 (regular) Quality: Tender to touch and movement R: 18 (regular) Region/Radiation: Both breasts BP: 125/80 Severity: 4/10 but better if wears a bra O2 sat: not assessed Timing: For the past couple of months What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: Breast tenderness; touch and movement; pain 4/10 relieved when wearing a bra. Breast tenderness is a presumptive sign of pregnancy. Current Assessment: GENERAL APPEARANCE: Calm, body relaxed, no grimacing, appears to be slightly nervous, Height 5’4” (160 cm), weight 100 lbs. (45.5 kg), 5 lbs. (2.3 kg) weight loss from pre-pregnant weight, no appetite. BMI 18 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, equal with palpation at radial, brisk cap refill NEURO: Alert and oriented to person, place, time, and situation (x4) HEENT: Normal cephalic, slight bleeding at gum lines. Conjunctiva of eyelids; appears pale Chest: Breasts tender on palpation, areola darkened and occasional veins present Abdomen: Soft; no masses, uterus palpable below the level of the symphysis pubis, Extremities: Mild spider varicose veins on the medial aspect of the left leg, deep tendon reflexes 2+ Pelvic Exam: Vagina and cervix deep purple in color, uterus slightly enlarged, and Hegar’s sign present What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT Assessment Data: Clinical Significance: - Patient slightly nervous has also lost weight from her pre-pregnant weight (105 lbs), now weighs (100 lbs); BMI 18. - Slight bleeding at gum lines, eyelids appears pale. - Mild spider varicose veins on medial aspect of left leg. - Vagina and cervix deep purple in color, uterus slightly enlarged, and Hegar’s sign present. - Since patient was underweight before her losing 5 lbs is significant, she will need to gain weight to ensure adequate nutrition for the fetus. - Slight bleeding at gum lines may be due to increased estrogen which can lead to gingivitis. Pallor may indicate anemia. (McKinney et al., 2018, pg. 218 & 226) - Venous congestion occurs since the blood return from leg veins is partially obstructed, which cause stasis of blood and venous distention. (McKinney et al., 2018, pg. 217) - Vagina & cervix deep purple in color; chadwick sign is a presumptive sign of pregnancy. The isthmus is soft and can be compressed which is the Hegar’s sign that occurs 6 to 8 weeks after last menses, a probable sign of pregnancy. (McKinney et al., 2018, pg. 221 & 223) Lab Results: Prenatal Panel Hemoglobin RPR/VDRL HBsAG Blood type Rubella HCG ELISA Current: 11.0 mg/dL Negative Negative B- Non- immune 20,700 mlU/ml Negative What lab results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: - Blood Type: B- - Rubella: Non- immune - Mother-fetal blood incompatibility, Rhogam will be given during pregnancy and after birth. (McKinney et al., 2018, pg. 227) - Since mother is non-immune, she will need a rubella vaccine postpartum. (McKinney et al., 2018, pg. 227) Urine Dipstick Color: Clarity: Sp. Gr. Protein Glucose Ketones Leukocytes/Nitrite Blood Chlamydia Gonorrhea Current: Yellow Clear 1.010 neg neg neg none none positive What lab results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: - Chlamydia/Gonorrhea: This stuPdyossoituirvcee was downloaded by Patient will need to be treated with antibiotics and will need to be retested during 3rd trimester to 1e0n0s0u0r0e80s4a8f3e1d21e1lifvroemryCfoourrstehH. on :49:58 GMT -05:00 Part II: Put it All Together to THINK Like a Nurse! 1.Interpreting relevant clinical data, what is the primary concern? What primary health related concepts does this primary problem represent? (Management of Care/Physiologic Adaptation) 2. What nursing priority (ies) will guide your plan of care? (Management of Care) Nursing PRIORITY: Imbalanced Nutrition: less than body requirement r/t growing fetus PRIORITY Nursing Interventions: Rationale: Expected Outcome: 1. Conduct a nutrition screen using the 1. The MUST tool was shown to be reasonably 1. Patient will identify Malnutrition Universal Screening Tool effective in identifying patients at risk of malnutrition nutritional requirements (MUST), is considered a quick easy-to-use when compared with PG-SGA with a sensitivity of and consume foods that tool to assess body mass, unintentional 69.7 % (Sharma et al, 2017). promote fetal growth weight loss acuity of illness and nutritional throughout her intake. (Gulanick & Meyers, 2017, pg. pregnancy. Patient will 652). progressively gain weight by her next 4 week appointment. 3. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? Psychosocial PRIORITIES: Anxiety r/t unknown future as evidence by patient appearing slightly nervous. Nursing Interventions: Rationale: Expected Outcome: CARING/COMFORT: How can you engage and show that this pt. matters to you? Physical comfort measures: Making sure that the patient feels safe and comforted, reassuring her that any support she may need will be provided throughout her pregnancy. Having an open body language, and actively listening to her concerns in the situation with her parents and ex boyfriend. Provide any additional needs; if patient needs a hug or a shoulder to lean on, or a hand to hold. Patient is able to express any concerns and her feelings about her situation. This is also building trust with the nurse. EMOTIONAL SUPPORT: Principles to develop a therapeutic relationship Actively listening to the patient and expressing her feelings about the concerns she has telling her parents and ex boyfriend about the pregnancy. Providing support if needed to tell them about the pregnancy. Patient will feel supported and will express her emotions about they pregnancy with her patents and ex boyfriend. SPIRITUAL CARE/SUPPORT: Reassuring the patient that she isn’t alone, and feels supported and comfort throughout her pregnancy. Providing brochures and available information regarding spiritual resources. Patient will have decreased feelings of loneliness throughout her pregnancy, and attend spiritual support groups. 4. What educational/discharge priorities will be needed to develop a teaching plan for this patient? (Health Promotion and Maintenance) Education PRIORITY: PRIORITY Topics to Teach: Rationale: 1. Education about the physical changes that will occur throughout pregnancy. Providing nutritional information, and recommended pregnancy weight. 2. Coping mechanisms that will help her with the changes and support groups. 3. Provide education on why the Rhogam shot is needed at 28 weeks and what it is for. 4. Educate patient on signs and symptoms of labor, and abnormal signs that she may need to seek medical treatment for. 1. This will provide her the information needed to make sure she is able to gain the appropriate weight for her pregnancy while making nutritional choices that benefit fetal development. 2. Patient will be less anxious knowing that the physical changes, and symptoms are normal during pregnancy. 3. Patient knowing about the shot and reasons will ease her worries and address any concerns she may have. 4. Being aware of what to watch out for will prevent complications for her and the baby, and when to notify her PCP and visit the hospital. Use Reflection to THINK Like a Nurse What Did You Learn? What did you do well in this case study? The importance of nutrition during pregnancy, how that effects the fetal growth and development. Also how important it is for teens during an unplanned pregnancy are still able to maintain balance and going through the transitional change from being an adolescent and adjusting to the changes to come. Making sure that the patient was aware of how important nutrition is and help make better nutritional choices. What could have been done better? What is your plan to make any weakness a future strength? Understanding the emotional support that teen’s need during an unplanned pregnancy and what challenges that may come with. Become knowledgeable of the resources that are out there and what support there is for teen parents. 1. What did you learn that you can apply to future patients you care for? Reflect on your current strengths and weaknesses this case study identified. What is your plan to make any weakness a future strength?