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Case Study

This case study examines the demographics, medical history, and labor and delivery experience of Jessica Thompson and Erika Tallman. It also includes information on topics such as cervical cerclage, tubal ligation, and postpartum care.

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Case Study

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  1. Case Study Jessica Thompson And Erika Tallman

  2. Demographics • T.L. • 29 years old • G6P5AB1L4 • LMP 8/31/10 • baby girl • 6 lbs 7oz • Born 6/1/11 at 1709 • 39weeks and 1 day gestation. • EDD 6/7/11 • Bottle feeding (Maternal preference)

  3. OB history • Pregnancy #1:was an ectopic pregnancy. • Pregnancy #2: resulted in the preterm labor at 36 weeks. • Pregnancy #3: resulted in another preterm labor at 35 weeks. • Pregnancy #4: resulted in fetal demise at 32 weeks gestation related to cervical funneling. • Pregnancy #5: resulted in a full term baby boy. • Pregnancy #6: resulted in a full term baby girl.

  4. Fatal Pregnancies • IUFD Occurred at 32 weeks gestation when cervical funneling (cone shaped indentation in the cervical os took place) which she birthed. • Ectopic Occurred when the ovum implanted into a site other than the lining of the uterus.

  5. Incompetent cervix • Painless dilation of the cervix without contractions because of a structural or functional defect of the cervix. • Related risk factors include: multiple gestations and previous preterm births • Education would include the warning signs of preterm labor: lower back pain, pelvic pressure, and changes in vaginal discharge; and the benefits of a cerclage placement.

  6. Cerclage • Surgical procedure in which the cervix is sewn shut primarily in the third month pregnancy (T.L. had this done at 13 weeks, laproscopically), to keep the cervix from prematurely dilating. • Successful in 80-95% of cases. • Generally removed in the 37th week of pregnancy, but can be removed earlier if ROM or true labor contractions occur. Cervical Cerclage, 2006

  7. Fogelson, 2010

  8. video http://www.youtube.com/watch?v=630Ax6N6yp0&feature=autoplay&list=PLB5A0A679455613C2&index=1&playnext=2 (elitelaproscopic, 2010)

  9. J. Ludmir

  10. PP Bilateral tubal ligation“having your tubes tied” • Permanent, irreversible form of birth control that is over 99% effective. • Procedure includes making an incision just above the navel and using laparoscopic tools to snip the fallopian tubes and cauterize them, pain is relieved through the use of anesthesia. • Can be done in an outpatient setting.

  11. Lab work

  12. Pregnancy Related tests

  13. Labor and Delivery • T.L’s labor was induced when her Cerclage was removed on 5/31/11 and amniotomy at 1915, with an epidural, LR with pitocin, and a foley bulb, her labor took 22 hrs, with a 9 minute 2nd stage and a 3 minute 3rd stage, with 250mL blood loss and a 2nd degree laceration. • Because T.L. was gbs+, she was also taking penicillin via a IV piggyback.

  14. Labor and Delivery contd. • FHR remained in the 130s bpmwith moderate variability, monitored consistently with an external transducer. • The baby girl scored a 9 out of 10 on the APGAR scale at 1 and 5 minutes of age.

  15. PP assessment Vitals • 0900: BP 124/76, HR 70, R 14, T 36.7 • Pain 0/10 • 1400: BP 122/74, HR 66, R 14, T 36.5 • Pain 4/10- medicated with vicodin and motrin • BUBBLE-HEB was within normal limits

  16. Newborn assessment Vitals • 0800: HR 140, R 45, T 36.5 • Pain 0/10 • 1500: HR 150, R 45, T 36.5 • Pain 0/10 • Reflexes present • Skin and mucosa within normal limits • fontanels soft and level • Symmetrical movements • Voiding adequatelt

  17. Newborn Feedings • T.L.’s choice to not breastfeed, the baby girl now gets her nutrition through Similac advanced formula every 3-4 hours. • Feedings • 0530- 22cc • 0900- 20cc • 1130-5cc • 1300-5cc • 1530- 5cc

  18. PP medications • Vicodin: Opiod analgesic, generalized CNS depression for moderate pain. 1 tab (5mg) q4hr PO : not to exceed 4000mg/day. • Prenatal vitamin: with iron supplement. 1 tab/day • Motrin: nonopiod analgesic/nonsteroidal anti-inflammatory/ antipyretic: inhibits prostaglandin synthesis. Prn: 600 mg q6hr PO • Americaine ointment: anesthetic, local pain relief Prn applied topically • Tucks(witch hazel) pads: analgesic, local pain relief R/T hemorrhoids. Prn applied topically

  19. education Nursing Diagnosis #1 Risk for infection • AEB… inadequate primary defenses, invasive procedures and environmental exposure. • Normal labor trauma • Tubal procedure • Not as active • Hospital environment Goal: Be free of purulent drainage or secretions, and other signs of infections throughout the healing process. Evaluation: At this time the patient was free of infection and expressed understanding of education.

  20. Intervention 1 Check and chart vitals every shift for comparison. Monitor and educate on the following for signs of infection: ■Redness, swelling, increased pain, or purulent drainage at incisions, injured sites, exit sites of tubes, drains, or catheters Any suspicious drainage should be cultured; antibiotic therapy is determined by pathogens identified at culture. ■Elevated temperature Fever of up to 38° C (100.4° F) for 48 hours after surgery is related to surgical stress; after 48 hours, fever above 37.7° C (99.8° F) suggests infection; fever spikes that occur and subside are indicative of wound infection; very high fever accompanied by sweating and chills may indicate septicemia. ■Color of respiratory secretions Yellow or yellow-green sputum is indicative of respiratory infection. ■Appearance of urine Cloudy, foul-smelling urine with visible sediment is indicative of urinary tract or bladder infection. Give written information about signs of infection Physician should be notified of any signs or symptoms of infection

  21. Intervention 2 Wash hands before and after client care Teach patient or caregiver to wash hands often, especially after toileting, before meals, and before and after administering self-care. Patients and caregivers can spread infection from one part of the body to another, as well as pick up surface pathogens; hand washing reduces these risks. Note patient understanding of education given Note patient compliance of proper perineal cleanser and hygiene

  22. psychological Nursing Diagnosis #2 Risk for disturbed body image • AEB… situation, focus on past appearance, change in social involvement • Multiple pregnancies • 40 lbs weight gain, wishes to lose all • Newborn to care for Goal: improve and maintain self-esteem through the first post-partal year illustrated verbally. Evaluation: At this time the patient is unsatisfied with current body weight and BMI illustrated by verbal negativity.

  23. Allow patient to initiate conversation about subject of her body Intervention 1 Note patient’s behavior regarding actual or perceived changed body part or function. There is a broad range of behaviors associated with body image disturbance, ranging from totally ignoring the altered structure or function to preoccupation with it. Promote patient to communicate concerns with family and healthcare provider Give information about realistic weight loss goals

  24. Be positive in conversations Intervention 2 Assist patient in incorporating actual changes into ADLs, social life, interpersonal relationships, and occupational activities. Opportunities for positive feedback and success in social situations may hasten adaptation Give information pertaining to breastfeeding and the extra calories burned along with the importance for the newborn Discuss healthy nutritional and physical activity options

  25. nutrition Nursing Diagnosis #3 Newborn: imbalanced nutrition: less than body requirements • AEB… lack of interest in food • Decreased intake Goal: maintain and increase weight, be free of signs of malnutrition daily and throughout early childhood Evaluation: At this time the patient is not having adequate intake

  26. Draw labs once daily for evaluation Intervention 1 Monitor laboratory values that indicate nutritional well-being/deterioration: Serum albumin: This indicates degree of protein depletion (3.8 to 4.5 g/dl is normal). Transferrin: This is important for iron transfer and typically decreases as serum protein decreases. RBC and WBC counts: These are usually decreased in malnutrition, indicating anemia and decreased resistance to infection. Serum electrolyte values: Potassium is typically increased and sodium is typically decreased in malnutrition Document any values off baseline/norm and notify physician Evaluate any supplemental options if lab values are abnormal

  27. Encourage frequent and possible smaller meals Intervention 2 Suggest ways to assist patient with meals as needed. This educates and encourages adequate feedings. Ensure a pleasant environment, to improve comfort levels both maternally and for the newborn. facilitate proper positioning; nipple placement and a proper latch facilitates feeding and provide good oral hygiene to reduce risk of aspiration Monitor weight gain and I&O Make sure formula is at a comfortable temperature, and nipple is appropriate

  28. physiological Nursing Diagnosis #4 Disturbed sleep pattern • AEB… situation and environmental changes • Previously prescribed sleep aide • Hospitalization • Newborn at home • 4th child living in household Goal: Verbalize increased sense of well-being and adequately rested within discharge and by the first follow-up doctors appointment Evaluation: At this time the patient is not getting adequate rest, illustrated verbally.

  29. Intervention 1 Provide comfort measures that assist in relaxation Identify factors that may facilitate or interfere with normal patterns. Knowledge of its role in health/wellness and the wide variation among individuals may allay anxiety, thereby promoting rest and sleep. Evaluate and educate on help from family and friends once at home Allow mother alone time to rest when she chooses

  30. Discuss sleep patterns effective with previous pregnancies Intervention 2 Instruct patient to follow as consistent a daily schedule for retiring and arising as possible. This promotes regulation of the circadian rhythm, and reduces the energy required for adaptation to changes. Provide information on the importance of sleep and various tricks to allow for adequate sleep. Monitor current sleep pattern and consult with physician for pharmacological measures if needed.

  31. References Gulanik, Myers, Klopp, Galanes,. (2009). In EHS: Nursing Care Plans: Diagnosis and Intervention. Retrieved Jun. 8, 2011, from http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor Harmat, L., Takács, J., & Bódizs, R.. (2008). Music improves sleep quality in students. Journal of Advanced Nursing, 62(3), 327. Retrieved June 13, 2011, from ProQuest Nursing & Allied Health Source. (Document ID: 1468397021). Louey, M.. (2006). Formula Feeding: Fluid Evidence Summaries. Retrieved June 13, 2011, from Evidence-Based Resources from the Joanna Briggs Institute. (Document ID: 1445804761). Ludmir, J. In Ultrasound Criteria for the Diagnosis of Incompetent Cervix. Retrieved Jun. 8, 2011, from http://www.fetalultrasound.com/online/text/33-039.htm Stulberg JJ, Delaney CP, Neuhauser DV, AronDCm FU P, Koroukian SM. Adherence to Surgical Care Improvement Project Measures and the association with postoperative infections. JAMA. 2010; 303(24): 2479-2485. • (2006). In Cervical Cerclage. Retrieved Jun. 7, 2011, from http://www.americanpregnancy.org/pregnancycomplications/cervicalcerclage.html • Body Image Disturbance; Weight training may be effective for body- imaged-disturbed college women :[1]. (2004, November). Obesity, Fitness & Wellness Week,141. Retrieved June 13, 2011, from ProQuest Nursing & Allied Health Source. (Document ID: 738930181). • Doenges, M, & M. Moorhouse, & A. Murr. (2010). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span. Philidelphia, PA: F.A. Davis. • elitelaproscopic,. (2010, Mar. 3 ). In LaproscopicCervioc-Isthmic Cerclage. Retrieved Jun. 7, 2011, from http://www.youtube.com/watch?v=630Ax6N6yp0&feature=autoplay&list=PLB5A0A679455613C2&index=1&playnext=2 • Fogelson, N.. (2010, Feb. 27 ). In Cerclage How-To . Retrieved Jun. 7, 2011, from http://academicobgyn.com/2010/02/27/academic-obgyn-cases-abdominal-cerclage-how-to

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