Maternity Case 2
Olivia Jones (Complex)
Virtual Simulation:
Maternity Case 1 Part 2: Olivia Jones (Complex)
Scenario Overview
Patient name: Olivia Jones
Diagnosis: Severe preeclampsia
Learning Objectives
General:
Identifies the primary nursing diagnosis
Identifies relevant patient history information
Implements patient safety measures
Identifies physical findings and diagnostics related to patient condition
Implements provider orders appropriately
Implements nursing interventions based on patient care needs
Prioritizes nursing interventions
Provides patient/family education and teaching
Recognizes therapeutic and confidential communication techniques
Reports findings directly and accurately to interprofessional team members
Utilizes members of the health care team when appropriate
Scenario Specific:
Recognizes signs and symptoms of severe preeclampsia (hypertensive disorders)
Performs focused antepartum assessment of patient with severe preeclampsia
Performs focused antepartum assessment of fetus
Communicates severe preeclampsia to the interprofessional team
Administers prescribed antihypertensive medication (magnesium sulfate)
Implements seizure precautions
Patient Case Introduction to Students
Location: Labor and birthing room
Time: 1500 h
Olivia Jones is a 23-year-old African-American female, G1P0 at 36 weeks of gestation. She has been diagnosed with severe preeclampsia and is admitted to the labor and delivery unit for assessment and surveillance.
Pregnancy has been unremarkable until routine prenatal visit at 30 weeks with elevated blood pressure at 146/92 mm Hg, proteinuria, and developing mild preeclampsia. She has been on bed rest at home until prenatal visit today with increasing symptoms, resulting in admission.
She has gained 3 pounds since prenatal visit 1 week ago. Protein dipstick is +4, negative ketones, negative glucose, +2 dependent edema, and facial puffiness.
Ms. Jones is complaining of a headache that is not resolved with acetaminophen. She presents with nausea and fatigue and complaining of epigastric pain, visual changes, and chest tightness. The fetus is active; however, patient states that it is a bit quieter than normal. There is a possibility of premature rupture of membranes. An IV with lactated Ringer’s is running at 125 mL/hr. Labs were obtained.
Patient Details
Patient Data: Female – Age 23 years. Weight 110 kg (243 lbs). Height 168 cm (66 in).
Gravida: 1 Para: 0
Gestation week: 36
Allergies: No known
Past Medical History: Unremarkable. Nonsmoker. Sedentary lifestyle. Denies history of diabetes, collagen disease, including Systemic Lupus Erythematosus; denies renal disease or history of hypertensive disease until development of preeclampsia at 30 weeks gestation.
Provider’s Orders 1
Nutrition:
NPO until serum lab results
Activity:
Bed rest
Assessment:
BP Q 15 min
Temp, HR, RR Q 15 min
Deep tendon reflexes Q 1 hour
Head-to-toe assessment Q 4 hours
Breath sounds Q 4 hours
Continuous pulse ox
Obtain ultrasound (Indication: biophysical profile, amniotic fluid index)
One hour FHR/UC monitoring 3 times daily (Q 8 hours)
Precautions:
Minimize outside stimuli
Labs:
Comprehensive metabolic panel, STAT
Hepatic function panel, STAT
Meds:
Promethazine 25 mg tbl P.O. PRN if she’s nauseated
Lactated Ringer’s 500 mL IV bolus x 1 (For nonreassuring fetal heart pattern)
Respiratory:
Oxygen 10 L/min per non-rebreather mask for nonreassuring (Category II or III) fetal heart rate. May discontinue oxygen when fetal heart returns to reassuring (Category I)
Call orders:
Temp 100.4°F (38°C)
HR 100
RR 24
BP sys 140; dia > 90
SpO2 < 94%
Nonreassuring fetal HR
Other: rupture of membranes, vaginal bleeding, abdominal or epigastric pain
Provider’s Orders 2
Assessment:
Temp Q 4 hours
Pulse Q 15 minutes during magnesium sulfate bolus, then Q 1 hour
Blood pressure Q 15 minutes during magnesium sulfate bolus, then Q 1 hour
Respiratory rate Q 15 minutes during magnesium sulfate bolus, then Q 1 hour
Assess respiratory status for cough, shortness of breath and breath sounds Q 2 hours
Assess hourly for headache and visual changes
Assess for nausea, vomiting, epigastric pain, upper right quadrant pain Q 2 hours
Deep tendon reflexes Q 2 hours
Med:
Give magnesium sulfate 6g in 100 mL sterile water loading dose IV over 30 min.
Following loading dose, give magnesium sulfate 20 g in 500 mL sterile water at 50 ml/hr.
Call orders:
RR 26
BP sys > 160; dia > 110
Urine output less than 30 mL/hour with Foley
Absent deep tendon reflexes
Nursing Diagnoses
Anxiety related to hospitalization and concern about health status and condition of fetus
Deficient Fluid Volume related to fluid shift from intravascular to extravascular space 2° vasospasm
Risk for Injury (to the fetus) related to uteroplacental insufficiency 2° to vasospasm
Decreased Cardiac Output related to decreased venous return
Case Considerations
Preeclampsia with onset prior to 32 weeks of gestation is associated with a 20-fold higher risk of maternal mortality compared to onset at term. The symptoms associated with severe preeclampsia are defined as preeclampsia with additional increases in blood pressure to 160-180/110 mm Hg, heavy proteinuria, visual changes, epigastric pain, elevated creatinine levels, pulmonary edema, oliguria less than 500 mL/24hr, intrauterine growth restriction of oligohydramnios, and hepatic dysfunction. Although triggering factors are unknown, risk factors include familial history, periodontal disease, African-American descent, and preexisting conditions such as renal disease, collagen disorders, chronic hypertension, and diabetes.
Treatment for severe preeclampsia includes reduced activity, strict bed rest, IV antihypertensives such as magnesium sulfate, and preparation for delivery. The primary objective for pregnant women with hypertensive disorders is always optimal safety for the mother and fetus. Delivery is considered when it is possible to promote health for both mother and fetus without admission in critical care areas, including neonatal intensive care. If disease processes continue and affect maternal health status, the only option may be delivery, regardless of gestational age.
Scenario Log:
PLEASE NOTE THE FOLLOWING:
“YOU” IN THE SCENARIO LOG REFERS TO YOUR VIRTUAL PRECEPTOR; (IMAGINE AN RN YOU ARE SHADOWING AND OBSERVING FOR THE DAY.)
“SHE” IN THE SCENARIO LOG, REFERS TO THE VIRTUAL PATIENT.
0:00
You arrived at the patient.
0:00
You introduced yourself.
0:10
Patient status – Heart rate: 111. Pulse: Present. Blood pressure: 172/102 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 92%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 153.
0:13
You washed your hands. To maintain patient safety it is important to wash your hands as soon as you enter the room.
0:56
Patient status – Heart rate: 111. Pulse: Present. Blood pressure: 170/102 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 91%. Temp: 37 C. EFM: Occasional acceleration. Fetal heart rate: 154.
1:28
You identified the patient. To maintain patient safety it is important that you quickly identify the patient.
1:51
You attached the automatic noninvasive blood pressure (NIBP) measurement cuff. This will allow you to reassess the patient continuously.
1:56
Patient status – Heart rate: 112. Pulse: Present. Blood pressure: 168/101 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 91%. Temp: 37 C. EFM: Occasional acceleration. Fetal heart rate: 164.
2:03
You checked the ;temperature; at the mouth. The temperature was 37 C.
2:06
Patient status – Heart rate: 112. Pulse: Present. Blood pressure: 172/103 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 91%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 160.
2:42
You attached the Pulse oximeter; This was indicated by order.
2:56
You checked the radial pulse. The pulse is strong, 115 per minute and regular. It is correct to assess the patient’;s vital signs.
3:06
Patient status – Heart rate: 112. Pulse: Present. Blood pressure: 170/102 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 90%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 157.
3:15
You looked for normal breathing. She is breathing at 22 breaths per minute. The chest is moving equally.
3:35
Patient status – Heart rate: 112. Pulse: Present. Blood pressure: 172/103 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 90%. Temp: 37 C. EFM: Occasional acceleration. Fetal heart rate: 159.
3:53
You phoned the provider in order to discuss the patient.
4:35
Patient status – Heart rate: 112. Pulse: Present. Blood pressure: 172/102 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 90%. Temp: 37 C. EFM: Occasional acceleration. Fetal heart rate: 170.
4:45
Patient status – Heart rate: 112. Pulse: Present. Blood pressure: 174/103 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 89%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 166.
5:45
Patient status – Heart rate: 113. Pulse: Present. Blood pressure: 174/104 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 89%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 165.
6:05
You examined the patient;s head. There is no obvious airway obstruction. There is normal elasticity of the skin. Her skin is cool and she is very sweaty.
6:23
You examined the patient;s chest. She is breathing at 22 breaths per minute. The chest is moving equally. There is normal elasticity of the skin. Her skin is cool and she is very sweaty.
6:41
You asked the patient: Where does it hurt? (In pain) She replied: ;It hurts in the upper center of my stomach and under my right breasts;
6:45
Patient status – Heart rate: 113. Pulse: Present. Blood pressure: 173/103 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 89%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 167.
7:13
You listened to the heart of the patient. This is reasonable. There were regular heart sounds without murmurs.
7:42
You listened to the lungs of the patient. There are crackles at both bases.
7:45
Patient status – Heart rate: 113. Pulse: Present. Blood pressure: 173/103 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 88%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 169.
7:54
You examined the patient’s abdomen and pelvis. Leopold;s maneuvers were performed. The fetus is in longitudinal lie, in vertex presentation. There is normal elasticity of the skin. Her skin is cool and she is very sweaty.
8:15
You examined the patient;s arms. There is normal elasticity of the skin. Her skin is cool and she is very sweaty. There is nothing else to find on examination of the arms.
8:31
You examined the patient;s legs. There is normal elasticity of the skin. Her skin is cool and she is very sweaty. There is nothing else to find on examination of the legs.
8:45
Patient status – Heart rate: 112. Pulse: Present. Blood pressure: 174/103 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 88%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 170.
8:56
You checked for edema. This was reasonable. There is a moderate to severe pitting edema graded to +3.
9:18
You checked the fetal heart rate by auscultation. This was reasonable. The fetal heart rate was 170 beats per minute. The fetus was tachycardic.
9:44
You attached the electronic fetal monitoring device.
9:45
Patient status – Heart rate: 112. Pulse: Present. Blood pressure: 170/102 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 88%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 171.
9:57
You palpated the uterus for contractions. The uterus tone was moderate between contractions. No contractions was noted. Fetal movement was felt.
10:23
You gave the patient 100% oxygen from a nonrebreathing mask. This was part of your orders.
10:25
You turned the oxygen on.
10:45
Patient status – Heart rate: 113. Pulse: Present. Blood pressure: 171/101 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 90%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 167.
11:09
You requested an ultrasound examination.
11:45
Patient status – Heart rate: 109. Pulse: Present. Blood pressure: 166/100 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 94%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 152.
12:29
You checked the deep tendon reflexes. This was reasonable. The deep tendon reflexes were very brisk, hyper reflexive, and with clonus. Graded to +4.
12:45
Patient status – Heart rate: 105. Pulse: Present. Blood pressure: 166/99 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 96%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 151.
12:55
You placed a urinary catheter. Its correct to insert a urinary catheter to monitor the patient’s urine output and treatment response.
13:13
You put up seizure pads on the bed. This was indicated by order.
13:26
You minimized outside stimuli.
13:32
You asked the patient if she had a headache. (In pain) She replied: Yes.;
13:45
Patient status – Heart rate: 103. Pulse: Present. Blood pressure: 166/100 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 151.
13:45
You asked the patient if she had experienced any visual changes. (In pain) She replied: My vision is blurred and I can see some spots.;
14:04
You phoned the provider in order to discuss the patient.
14:45
Patient status – Heart rate: 101. Pulse: Present. Blood pressure: 166/99 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 151.
15:23
You assessed the patient’s IV. The site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact. This is correct. Assessing any IVs the patient has is always important.
15:45
Patient status – Heart rate: 101. Pulse: Present. Blood pressure: 163/98 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 98%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 150.
16:06
You obtained ;IV_access; in the antecubital region.
16:42
You verified the dose with another nurse. The dose was correct.
16:45
Patient status – Heart rate: 101. Pulse: Present. Blood pressure: 165/99 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 98%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 150.
17:45
Patient status – Heart rate: 101. Pulse: Present. Blood pressure: 167/100 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 98%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 150.
17:45
You started infusing magnesium sulphate in sterile water (6g in 100 mL) at 200 mL/hr. It is important to use the basic rights of medication administration to ensure proper drug therapy. This was indicated by order.
18:02
You provided patient education. This is correct. It is important to provide patient educate to improve understanding of the patient’s medical condition and methodes and means to manage her condition. Effective communication and patient education increases patient motivation to comply.
18:32
You checked the radial pulse. The pulse is strong, 100 per minute and regular.
18:45
Patient status – Heart rate: 101. Pulse: Present. Blood pressure: 166/99 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 98%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 150.
18:55
You looked for normal breathing. She is breathing at 22 breaths per minute. The chest is moving equally.
19:09
You ended the scenario by returning to the nurse’s station. This was reasonable.
Maternity Case 1 Part 2: Olivia Jones (Complex)
Documentation Assignments with SBAR communication
1. Document the data from the focused antepartum assessment of both Ms. Jones and the fetus.
2. Write the situation-background-assessment-recommendation (SBAR) communications you would use to update the provider on Ms. Jones’s status at the time of her admission.
3. Document the teaching you would provide to the patient and her support person prior to administering magnesium sulfate.
4. Document the administration of the magnesium sulfate bolus and the initiation of the magnesium sulfate infusion.
5. Document your reassessment of the patient’s status after administering magnesium sulfate.
QSEN guided Scenario Analysis Questions*
EBP What are the indications that Olivia Jones’s preeclampsia has progressed?
PCC What should the priority teaching for Olivia Jones include?
PCC/I Olivia Jones was placed on magnesium sulfate for treatment of her preeclampsia. What are the indications for this drug, and what should be taught to the patient regarding side effects?
T&C What key elements would you include in the handoff report for this patient? Consider the situation-background-assessment-recommendation (SBAR) format.
S What safety measures should be initiated while Olivia Jones is in the hospital?
S/QI Based on your experience with Olivia Jones’s case, reflect on possible nursing actions for enhanced safety and quality improvement.
Concluding Questions
Reflecting on Olivia Jones’s case, were there any actions you would do differently from the “preceptor” in the scenario? Explain.
Describe how you would apply the knowledge and skills that you obtained in Olivia Jones’s case to an actual patient care situation.
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