N 340 Women's Health & Illness in The Expanding Family & N345 Clinical Practicum

High Risk Postpartum Case Studies

Directions: Please read these and have a basic understanding of the nursing diagnoses and interventions including how you would prioritize the care. Please bring these to class. We will be dividing into groups to present your solutions based on the SBAR format. You will get a lot more out of the class if you have a "working" knowledge of all the case studies. Keep the case studies in mind as you read the chapters in your text and when referring to ATI.

1. Emily S.

Emily is a 15-year-old patient who had her first child 2 days ago. She is getting ready to leave the hospital this morning and is quite excited about “getting out of here.” Her MD came in earlier and discharged her and the Pediatrician discharged the baby. You are the nurse providing care for her today. The night nurse didn’t give a very good report to the oncoming day shift because another patient seized around 4 a.m. and someone else hemorrhaged. She did say something about Emily having a temperature of 101 at midnight.

You took care of Emily yesterday so you remember some of her history: She came into the hospital after her membranes had been ruptured for “a couple of days.” She labored for about 8 hours when the MD came in and checked her and she was 3 Cms dilated. He inserted an internal fetal monitor with a scalp electrode and also an intrauterine pressure catheter because she is obese and the L & D nurse was having a difficult time picking up the FHR tracing. She slowly progressed in labor and delivered 24 hours after she had been admitted. The baby was LGA and she had a third degree laceration. This laceration had been causing her a great deal of discomfort and so she had been taking Tylenol with Codeine every 3 to 4 hours.

On her prenatal history you had noticed yesterday that Emily was in a special high school for pregnant and parenting teens. She had been excited about being pregnant because most of her friends already had babies. She started getting PN care by the time she was 14 weeks pregnant and would have started sooner but she had to wait for her MediCal to “kick in.” By the end of her pregnancy she weighed 230 pounds (she gained 20 pounds during her pregnancy). She had a 22-year-old boyfriend and had been treated for gonorrhea and chlamydia during her pregnancy. He is now “out of the picture.” She had developed gestational diabetes during the pregnancy, but had seen the nutritionist several times who reported her diet was “excellent.”

You walk in Emily’s room to take a quick set of Vitals before breakfast is served. She is dressed and already to go home. Emily is just waiting for her mother to come and pick her up. Her VS are: T: 101.5 P: 102, BP 108/70 R: 20. You tell Emily she has a temperature and she immediately bursts into tears and asks, “Does this mean I can’t go home?”

What would you say? What would you do next?

Think about: What is your primary nursing diagnosis for Emily? What else causes an elevated temperature? What in your assessment leads you to believe there is a problem? What in her history supports your diagnosis? What other problems do you think Emily has? What positive things does Emily have going for her? Do you need any additional information?

SBAR:

2. Betty R.

 Betty is a 38-year-old woman who delivered twins three hours ago. This was her 5th pregnancy so she now has 6 children. Her oldest child is 9 years old. She and her husband are quite excited about the twins because they are both girls and they have four boys at home. The twins are 38 weeks gestation and doing fine in the nursery. She labored for about 3 hours and because the twins only weighed 5 pounds each she didn’t need an episiotomy. Things got a little weird after the twins were born in that the third stage of labor was about 45 minutes. The MD had to manually remove the placenta because of the long third stage. The placenta looked to be in one piece, but had two almost separate lobes, which made the MD think the twins had two separate placentas that had fused together. They gave her 20 units of Pitocin in the IV initially and now she has an IV running at 125 ml/hour with 20 units of Pit in the bag.

The L& D nurse wheels her into the postpartum room, gives you a quick report at the desk and races back to assist with another delivery. Before you go into check Betty you notice on her VS sheet that her pulse during the last hour has crept up from 88 to 102, her BP was 130/84 right after delivery and is now 124/74 and her respirations have remained around 20. She was medicated for uterine cramping about 1/2 hour ago with Norco 10/325 You skim the delivery sheet and notice that in addition to the long third stage she had an EBL of 600 mls.

You are going to head into her room to check her, but a light goes on in another one of your patient’s room so you pop into that room first thinking it will be a quick thing. The patient has gotten really dizzy while in the bathroom so she sits down on the floor. She is diaphoretic. You get her all taken care of and head into Betty’s room 20 minutes later.

She looks a little pale, but who wouldn’t after what she has been through? You check her VS. The only thing a little off is her pulse is 108, but she’s telling you the Norco 10/325 must not be working because she is still in pain. You check her fundus which is boggy and she has totally saturated her pad and there is about a 10 cm area of blood on the sheets. You massage it, but it’s still staying boggy.

What is your primary nursing diagnosis for Betty? What else could cause these symptoms? What in your assessment leads you to believe there is a problem? What would you do next?

After you do what you just did you head out to the desk and check orders. She has these medication orders: Norco 10/325 q 4 hours prn pain, Ambien q hs prn, Senokot at q h.s Pitocin 10 mg IM, Methergine 0.2 mg IM q 4 hours prn. What would you do?

SBAR:

3. Rachel M.

Rachel is a 39-year-old primipara who just delivered her first child. She had borderline blood pressures in labor ranging between 130/88 to 144/92, but she was in a lot of pain due to a long labor and a pitocin augmentation. She delivered after a 23-hour labor and it is now two hours postpartum. She has just been transferred to the postpartum floor. The MD and L&D nurses where worried that she might be developing pre-eclampsia so they have been watching her closely. She has an IV running of D5 NS with 20 units of pitocin at 150 ml/hr. She has a foley in because she was unable to urinate postpartum and besides it was a convenient way to check for proteinuria without a bunch of lochia mixed with urine that make checking protein in the urine difficult.

She is absolutely exhausted and doesn’t want you to disturb her so she can sleep. MD orders include checking her BP q 30 minutes, reflexes and proteinuria q 4 hours. You set the dynamap so checking BPs is as least invasive as possible.

It is now 4 hours after delivery. Her blood pressure is now 140/98, pulse is 84 and respirations are 14. Her reflexes are 3 +. She has one beat of clonus. She hasn’t been drinking many fluids because she has been sleeping. The foley has 120 mls of urine in it since you checked it 4 hours ago.

What is your primary diagnosis for Rachel? What else could be going on? What in your assessment (and her past history) leads you to this diagnosis and that there is a problem? What would you do next?

Her MD is still back in L&D and is in with another one of her patients who is crowning. You poke your head in the door to give her a report on Rachel. What other symptoms would you have asked Rachel about that you would also be reporting to the MD? The MD tells you to start some Magnesium sulfate following the usual protocol and that she’ll be over right after this delivery. What is the usual protocol?

Three hours later (you have been checking her more often than this however!) you are assessing Rachel. Her BP is 134/80, R: 10 and P: 62. Her reflexes are 2 + with no clonus. You had drawn some blood 2 hours before and the lab has just called to tell you the Magnesium level is 7.8, Hgb is 11.3, serum creatinine is 1.4. Which of these results are worrisome? What would you do?

SBAR:

4.  Jane M.

Jane delivered her first child after only three hours of labor. She was planning on having a home birth, but was 43 weeks and no longer fit the midwife’s protocols for a safe home birth. She was disappointed because she wanted to do everything natural. By nature, she is not a complainer. She did not want any interventions and she does not have an IV in. Everybody is pretty amazed she had a fast labor because her new baby boy weighed 9 lbs 8 ounces. She did push for almost two hours intermittently in a squatting position and had a second degree laceration. She had 10 units of Pitocin IM after delivery of the placenta. Now she, her husband and the baby are bonding.

It is now 2 hours postpartum. Being the conscientious nurse you are, you are checking her vital signs q 30 minutes and also are checking her fundus to make sure it is staying firm. You have also taught Jane to do this fundal check as she values her ability to take care of herself. She’s got ice on her perineum and has eaten a delicious hospital lunch. Her vital signs are fairly stable although her pulse has gone from 84 to 96 in the last hour. Her fundus remains firm and at U. You are checking her perineal pad about every hour and it always seems to have a little more blood on it then you would like to see (it’s almost saturated), but things seem fine otherwise.

What if anything would you do at this point?

An hour later (now three hours after delivery) the emergency light goes on in her bathroom. You quickly go in and both Jane and her husband are in the bathroom. Now you are in there too and things are a little cramped. Jane is sitting on the toilet, having just urinated and is pale and diaphoretic. Her worried husband is holding her up because she feels like she is going to faint. He informs you that he has been changing her pad in-between the pad changes you had been doing because she was bleeding a lot and didn’t want to bother you. Blood is dripping at a pretty good rate into the toilet.

What would you do?

You get Jane pack into bed and recheck her fundus, which is staying firm and at the U. She continues to bleed onto her pad and complains of perineal throbbing. What is your primary nursing diagnosis for Jane? What is the probable etiology? What are the signs and symptoms? What would you do next?

SBAR:

5. Erin M.

Erin is a 34 year old married woman who had her first child three weeks ago. She calls you to ask about finding a resource to get some help with breast feeding. Her newborn is really fussy and she doesn't seem to have enough milk. She is a dentist and plans on returning to work in three weeks and wants to be able to pump her breasts so the baby can continue to get breast milk. Her mother in law and her mother think she should quite breastfeeding since she will soon be is returning to work full time.

She and her husband are planning on hiring an au pair to take care of their baby, but their most recent "lead" just fell through. She sounds anxious and a bit overwhelmed. She is also having a difficult time sleeping and this making her irritable. Her appetite has decreased and she is concerned this is interfering with her ability to produce breast milk.

You are wondering if she may have postpartum depression (PPD). Based on her symptoms do you think her PPD is mild, moderate or severe and how would this effect your recommendations for follow-up?

She agrees to you asking her some questions related to PPD. She scores 12 out of 30 on the Edinburgh Postnatal Depression Scale (EPDS). Her answer to #10 is never.

What is your nursing priority? What recommendations would you make?

SBAR: