Abruptio Placentae with Preterm Labor and Delivery
Abruptio Placentae with Preterm Labor and Delivery
RAPID Reasoning
Michelle Moore, 38 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
1. Reproduction
2. Oxygenation
3. Pain
4. Clinical Judgment
5. Patient Education
Abruptio Placentae with Preterm Labor and Delivery
History of Present Problem:
Michelle Moore is a 38-year-old who is 29 weeks pregnant. She began prenatal care at 18 weeks gestation because she was waiting to become insured. She is currently in the Labor and Delivery Unit of the hospital following a call to her primary care provider. She reported that she had a sudden onset of constant severe uterine pain and began to notice that she had vaginal bleeding that bright red, soaked a maxi pad and then began soaking through her underwear. Her baby has not been moving as actively as normal since the pain and bleeding started.
Personal/Social History:
Michelle works at a fast-food restaurant, standing on her feet for long hours. She usually works in the evenings and weekends. She is estranged from the father of the baby. Michelle’s father is able to help her with childcare once or twice a week. Michelle denies substance use including alcohol during her pregnancy. Michelle smokes 10 cigarettes daily, and says that she has decreased usage, but the stress of the pregnancy and having little support makes it difficult for her to quit.
Michelle reports that she usually eats at work to save money, and most meals consist of fried foods and diet sodas.
Michelle has a small apartment, but says she often has difficulty paying the rent on time, since child care is so expensive. She has a six-year old son who was born prematurely at 35 weeks. Michelle was diagnosed with a partial abruption during that delivery.
Past Medical History (PMH):
Home Meds:
Pharm. Classification:
Expected Outcome:
· Gravida 4, Para 1 with a partial abruption at 35 weeks
· Two spontaneous abortions in the first trimester
· Menses began at age 12, are usually 29 days apart, lasting for 4-5 days, with moderate-to-light flow.
· Successfully breast fed her first child for 11 months.
· Vaccinations are up to date.
· Michelle is biracial: African American and Asian, and she was tested for sickle cell trait. Lab results reveal Michelle is a carrier of the trait. It is unknown if the father of the
baby is also a carrier.
1. Prenatal vitamin 1 tab PO daily
2. Acetaminophen 650 mg PO PRN every 6 hours for infrequent, mild headaches
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Data from Present Problem:
Clinical Significance:
RELEVANT Data from Social History:
Clinical Significance:
Patient Care Begins:
Current VS:
P-Q-R-S-T Pain Assessment (5th VS):
T: 98.5 F/ 36.9 C (oral)
Provoking/Palliative:
Constant, nothing makes it worse or better
P: 122 (regular)
Quality:
“knife-like”
R: 24 (regular)
Region/Radiation:
abdominal
BP: 132/64
MAP: 87
Severity:
9/10
O2 sat: 96% room air
Timing:
constant
What VS data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data:
Clinical Significance:
Current Assessment:
GENERAL
APPEARANCE:
5′ 4″ (162.5 cm) tall and weighs 165 pounds (75 kg), including 25 pounds (11.4 kg) she
gained during this pregnancy. Appears uncomfortable, groaning and holding abdomen
RESP:
Breath sounds clear with equal aeration bilaterally, labored respiratory effort
CARDIAC:
Pale, cool/dry, no edema, heart sounds regular with no abnormal beats, equal with palpation
at radial/pedal/post-tibial landmarks
NEURO:
Alert and oriented to person, place, time, and situation (x4)
FETAL Monitoring:
Electronic Fetal Monitoring:
Fetal heart rate 150, minimum variability trending towards absent variability around the baseline, late decelerations, no accelerations noted. Contractions are frequent: every 1-2
minutes; uterus is board-like upon palpation.
What assessment data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data:
Clinical Significance:
Fetal Monitoring Strip:
Interpretation:
Clinical Significance:
Medical Management: Rationale for Treatment and Expected Outcomes
Care Provider Orders:
Rationale:
Expected Outcome:
Prepare for immediate cesarean section in operating room (OR)
Oxygen 10 liters/minute via nonrebreather
Continuous fetal monitoring Strict I&O
Insert urinary catheter
Lactated Ringers (LR) 1000 mL bolus
screen for “maternal pack” that includes 6 units PRBCs, 4 units FFP, 1 apheresis pack of platelets. This ratio can be repeated as needed
PRIORITY Setting: Which Orders Do You Implement First and Why?
Care Provider Orders:
Order of Priority:
Rationale:
· Oxygen -10 liters/minute vis non-rebreather
· Continuous fetal monitoring
· Insert urinary catheter with urometer for hourly I and O
· Lactated Ringers (LR) IV 1000 mL bolus
· screen for “maternal pack” that includes 6 units PRBCs, 4 units FFP, 1 apheresis pack of platelets. This ratio can be repeated as needed based on labs
(Drawn per policy, usually every 4 hours for 24).
Lab Results:
Complete Blood Count (CBC:) (Pregnancy Values)
Current:
High/Low/WNL?
Previous:
WBC (5,000 – 15,000 mm 3)
15.1
14.8
Hgb (11.5-14 g/dL)
9.5
11.2
Platelets (150-350 x103/µl)
101
122
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
TREND:
Improve/Worsening/Stable:
Coags:
Current:
High/Low/WNL?
PT/INR (0.9-1.1 nmol/L):
1.7
PTT (29-35 seconds):
45
Fibrinogen (<80 mg/dL):
44
Kleihauer-Betke test (Positive if
>0.01 mL of fetal blood in the maternal circulation)
Positive
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
TREND:
Improve/Worsening/Stable:
Urine Analysis (UA:)
Current:
WNL/Abnormal?
Previous:
Color (yellow)
Dark amber
Clear yellow
Protein (neg)
Neg
Neg
Glucose (neg)
Neg
Neg
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
TREND:
Improve/Worsening/Stable:
Clinical Reasoning Begins…
1. What is the primary problem that your patient is most likely presenting with?
2. What is the underlying cause/pathophysiology of this primary problem?
3. What nursing priority (ies) will guide your plan of care? (if more than one-list in order of PRIORITY)
4. What interventions will you initiate based on this priority?
Nursing Interventions:
Rationale:
Expected Outcome:
5. What psychosocial needs will this patient and/or family likely have that will need to be addressed?
6. How can the nurse address these psychosocial needs?
7. What body system(s) will you assess most thoroughly based on the primary/priority concern?
8. What is the worst possible/most likely complication to anticipate?
9 What nursing assessments will identify this complication EARLY if it develops?
10. What nursing interventions will you initiate if this complication develops?
11. If the worst possible/most likely complication was recognized by the nurse, when would you decide to notify rapid response team to evaluate further?
Education Priorities/Discharge Planning
1. What will be the most important discharge/education priorities you will reinforce with his/her medical condition to prevent future readmission with the same problem?
2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?
Caring and the “Art” of Nursing
1. What is the patient likely experiencing/feeling right now in this situation?
2. What can you do to engage yourself with this patient’s experience, and show that he/she matter to you as a person?
Use Reflection to THINK Like a Nurse
Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment.
1. What did I learn from this scenario?
2. How can I use what has been learned from this scenario to improve patient care in the future?