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A Case Study in Preeclampsia(please read through and check the questions at the last part)
Answer Key
Case Study—Background.
At 10:00AM your patient KT, who is 33 2/7 weeks arrives to L&D from her practitioner’s office where she had an elevated blood pressure. She is on observation.
41 years old
1 – 0 – 0 – 0 – 0
Blood pressure in the office is 142/90
6-pound weight gain since last visit
You introduce yourself and ask her about her family/partner. You stress that right now KT is here under observation to make sure everything is stable and to rule out preeclampsia.
Question 1: Think About It
What assessments do you immediately complete as you begin to determine if your patient has preeclampsia?
The initial assessments:
BP (antecubital space for mannequin)= 150/92
Weight (have a scale present)= 168
Headache (head, forehead)= negative
Epigastric pain (upper abdomen) = negative
Vision changes (eyes)= negative
Deep Tendon Reflexes + clonus (knee)= +1
Edema in extremities (lower legs) = present and pitting +1
LOC (head, middle of head)= A&O x 3
Heart (left side of upper chest)= normal S1 S2, HR 80
Lungs (middle of chest plus finger)= clear bilaterally, RR 18; Pulse ox 99%
Renal (bladder)= Normal output & +1 protein
Fetal Monitoring (on middle of belly)= FHR 158 and reactive
Room assessment for oxygen and suction set up (show oxygen and suction set up)
Question 2: Open Response
What education do you need to provide to your patient KT while completing the assessments?
Answer:
Explain that preeclampsia is not just elevated B/Ps. It can affect the entire body and it can be serious, explain preeclampsia. Explain that it can worsen over time and that is why we watch carefully. It is more unusual, but a woman can have eclamptic seizures or even a stroke with preeclampsia.
Discuss that as we try to rule out preeclampsia, we will monitor many things. We need to assess frequent BPs every 30 minutes. If she has a headache, epigastric pain, or vision changes notify the nurse and you ask her this at least once a shift because this could demonstrate a worsening disease process. Every four to eight hours we will: monitor her reflexes because with preeclampsia a woman can become hyperreflexic, check her extremities for fluid that is in the tissues, and listen to her heart and lungs. We will be measuring her urine output and will collect her urine for a 24-hour specimen. Right now, we will continuously monitor the baby. We will check her weight and if she stays overnight, we will check her weight in the morning.
Case Study—Continued
You document your assessments and patient education.
You discuss that you will be drawing some blood and need a urine specimen to get baseline lab values that you compare to future lab results.
Your standard order set for rule out preeclampsia includes obtaining these labs:
Urine for protein and begin 24-hour collection
Protein to Creatinine ratio
CBC with platelets
Coag profile
Serum Creatinine Clearance and uric acid
Liver enzymes ALT & AST
Chemistry
Question 3: Open Response
What is key when reviewing lab results and ongoing lab results?
Answer:
Trending. It demonstrates a worsening of the disease process. We want to see if the protein to creatinine ratio changes. What amount of protein is in the urine? If we see platelets drop below 100,000 or liver enzymes rise it demonstrates a worsening of the disease or possible progression to HELLP syndrome.
Case Study—Continued
SBAR with physician:
Your SBAR includes your above assessment and the above labs that you obtained with the primary practitioner.
The primary practitioner states, “sounds good” and contact with anything significant.
Question 4: Open Selection
What else should be included on the standard order set to rule out preeclampsia?
Complete bed rest (CBR)
Bedrest with bathroom privileges
Up ad lib
NPO
Clear liquids
Regular Diet
Continuous fetal monitoring
Fetal monitoring NST every 8 hours
Position patient on side lying with head of bed raised
Position patient flat on back with one pillow
BP every 30 minutes
HR, RR and T every four hours
VS every four hours
Contact practitioner if B/P >160/ >100
Contact practitioner if B/P >130/>80
Contact practitioner if B/P >140/>90
Case Study—Continued
At 10:45 the practitioner calls back and states, “Add to the orders administration of Betamethasone 12mg IM now and 12mg IM in 24 hours.” You document the medication administration at 10:50.
Question 5: Open Response
What education do you provide to your patient?
Answer:
Since your baby is premature the lungs are not fully developed. If you need to deliver your baby early because of preeclampsia you are receiving Betamethasone which is a steroid that helps the baby’s lungs to develop surfactant which helps the baby breathe better and without assistance.
The medication is two doses IM which are given 24 hours apart. The full effect of the medication begins 24 hours after the second dose.
This medication is very viscous and will be more painful than a normal medication injection.
Case Study—Continued
BP trends:
10:00 150/92
10:30 148/92
10:45 140/90
11:00 146/88
11:15 144/92
11:30 142/90
11:45 146/94
12:00 150/90
12:15 138/86
12:30 146/88
Lab results:
Urine protein 290mg
Protein to Creatinine ratio 0.15
CBC H&H: 15g/dL / 40%
Platelets 150,000
Creatinine Clearance 80mg/dL
Uric Acid 85mL/min
ALT
AST
16units/dL
16units/dL
Chemistry WNL
The primary practitioner is notified of the lab results and wants to observe her for another four hours. If she is stable, they will send her to the antepartum floor.
At 6:15 the following BP trends are noted:
12:45 138/90
13:00 142/90
13:15 144/90
13:30 140/90
13:45 140/92
14:00 13888
14:15 142/90
14:30 142/90
14:45 140/92
15:00 140/88
15:15 144/88
15:30 142/88
15:45 140/86
16:00 140/90
16:15 140/90
16:30 138/88
The primary practitioner determines to continue observation but send the patient to the antepartum unit with NST every eight hours. Repeat labs at 06:00 a.m.
At 11:00 a.m. the antepartum unit calls with report to transfer the patient back to L&D. You received hand-off.
The following is communicated.
Question 6: Fill in the Blanks
Item Result
Significant (S) or
Not Significant (NS),
BP 162/94 (latest) S
I&O
General diet breakfast with 240mL water
660mL / 24 hours
S
HR 76 NS
Protein to creatinine ratio
Protein at 24 hours
.25
400mg
S
Platelets 125,000 S
ALT 18units/dL S
AST 18units/dL S
blood pressure meds None given S
Betamethasone not Not given S
Creatinine Clearance 130mL/min S
FHR Reactive NST NS
IV site Right wrist 18g LR running at 75mL/hr NS
Case Study—Continued
Your patient arrives down to L&D at 11:00. You contact the primary provider for orders.
Question 7: Open Response
What do you want to include in your SBAR from your hand-off that needs addressing?
Answer:
Betamethasone is needed and past due by 15 minutes. Platelets decreasing, a slight increase in ALT/AST, protein to creatinine ratio elevated beyond normal, and protein in 24-hour urine collection 400mg. Blood pressure meds are needed according to ACOG standards.
Case Study—Continued
After you greet your patient and settle her in bed on her side and begin fetal monitoring you obtain vital signs and BP is 158/89, IV on pump LR running at 75mL/hr. Oxygen and suction available in room.
Question 8: Think About It
What do you assess the patient for? (included are KT’s results)
Headache (-)
Epigastric pain (-)
Vision changes (-)
Reflexes +2
A&O x3
Heart normal S1 S2
Lungs clear bilat
Questions 9-13: Open Response
What do you view as your 1st priority?
Answer:
Betamethasone injection 12mg IM
Education: Pain with injection
What is your next priority?
Answer:
Recheck BP and antihypertensive med as per order.
11:20 162/92
Your primary provider orders one dose of Labetalol as per ACOG standards. What is the dose, route, and at what length of time?
Answer:
20mg IVP over two minutes
As per standard orders following what do you anticipate the next dose/route and length of time to be (if needed)?
Answer:
40mg IVP two minutes
At 11:35, the BP is 152/84 and BPs are ordered for every 15 minutes. Do you need to give another Labetalol?
Answer:
No
Case Study—Continued
BP Trends:
11:50 150/84
12:05 152/83
12:20 154/84
12:30 150/82
12:45 158/86
13:00 156/86
13:15 152/86
At 12:00:
Headache –
Epigastric pain –
Vision changes –
reflexes +2
A&O x3 yes
At 13:00:
Headache –
Epigastric pain –
Vision changes –
reflexes +2
A&O x3 yes
At 13:15
Patient complains of headache with some double vision. FHR 150 with 2 accelerations noted in the last 25 minutes. Epigastric pain is (-) and reflexes are +3
Labs just received:
Urine protein 400mg (from 24 hour specimen)
Protein to Creatinine ratio 0.3
CBC H&H: 22g/dL / 40%
Platelets 110,000
Creatinine Clearance 120mg/dL
Uric Acid 85mL/min
ALT
AST
21units/dL
21units/dL
Chemistry WNL
Questions 14-20: Open Response
What do you do next?
Answer:
You SBAR with the primary provider who decides it is time to commit to delivery and begin Magnesium Sulfate and induction of labor. The provider will be in to see the patient as soon as possible but wants you to discuss the plan with the patient and begin orders.
What is your plan? What do you need to do in order of importance?
Answer:
Notify charge nurse and ask for another RN for assist.
Begin educating patient
The CNL is rounding on patients and wants an update for your patient so a Huddle can be called on the unit. What are your significant updates to be shared at Huddle?
Answer:
Huddle should include change in patient’s status: new onset headache and epigastric pain, Labetalol administration and resulting BP, decision to begin Magnesium Sulfate and induction of labor of preterm baby.
What do you educate the patient on?
Answer:
S/s of Magnesium Sulfate (flushing, burning at the IV site, weakness), CBR, insertion of an indwelling urinary catheter, and continuous fetal monitoring. Another IV will be placed, need to induce (will probably take a while), let us know if any s/s change.
Why is an additional IV needed?
Answer:
If she needs any IV medications there must be an additional IV (antihypertensives).
What do you delegate to the RN who comes into assist you?
Answer:
Start another IV—preferably 16g LR, get Magnesium Sulfate and Pitocin for induction.
What do you do next?
Answer:
Prepare calculation
Case Study—Continued
The second IV, 16g, LR at 20mL/hr is placed in the patient’s left hand.
The pharmacy is out of loading dose bags due to a shortage of Magnesium Sulfate. You will need to give the loading dose from the maintenance Magnesium Sulfate bag.
Here are the orders. You and the other RN complete the calculations individually.
Questions 21-24: Open Response
Magnesium Sulfate 20g / 500mL LR. The bolus should be 4gm Magnesium Sulfate over 30 minutes. What is the rate the pump is set at and what is the volume to be infused (VTBI). Please show your work:
Answer:
500mL / 20g = 25mL / 1g
4g = 100mL
To run over 30 minutes you must double the rate to 200mL / hr = rate of pump
VTBI = 100mL (because that is 4g Magnesium Sulfate)
You and the other RN complete and confirm the calculation. You set the pump and the RN confirms. An appropriate dose is placed.
Before the RN leaves you review the orders and calculation for the maintenance dose of Magnesium Sulfate. The order reads: Maintenance dose Magnesium Sulfate 3g / hour. Both you and the other RN complete the calculation separately and compare your result:
Answer:
From above you know that 25mL = 1g Magnesium Sulfate or calculate this if it is unknown
3g Magnesium Sulfate / hr = 25mL x 3g Magnesium Sulfate = 75mL / hr
The RN confirms 75mL is placed on the pump
The bolus is completed and your order reads: Magnesium Sulfate 3g/hr with a total IVF of 125mL / hr. Since you determined the Magnesium Sulfate is 75mL/hr = 3g, what is the rate of LR?
Answer:
125mL (total hourly volume) – 75mL Magnesium Sulfate = 50mL
Therefore, 50mL LR
The other RN completes and confirms the calculation and verifies it is correctly put on the pump.
What safety measures do you want to provide in the room?
Answer:
Turn lights down with quiet environment, call light within reach, pad side rails, Calcium Gluconate in the room at readily available.
You begin Pitocin on your patient.
You place the indwelling urinary catheter on your patient.
Questions 25-27: Open Response
What is critical when inserting the indwelling urinary catheter and why?
Answer:
Sterile technique due to risk of infection
The CNL will assist the RN by contacting what disciplines for consult on this patient?
Answer:
Anesthesiologist and NICU in prep for delivery
What concern do you have immediately following the delivery?
Answer:
PPH because Magnesium Sulfate relaxes the smooth muscle of the uterus
Case Study—Continued
Your patient’s BP has been maintained below 160/90 during the induction of labor and your patient has no additional changes to VS and s/s preeclampsia.
Delivery of baby girl at 13:24 the next day.
NICU is present. Newborn baby girl born at 33 5/7 weeks goes to NICU.
Questions 28-29: Open Response
Has the Betamethasone reached its peak performance?
Answer:
Yes
How long will KT stay on Magnesium Sulfate post-delivery?
Answer:
24 hours
At many hospitals, she will remain in L&D for this time. At level 3 or 4 institutions she may go to the MB unit 12-hour post-delivery if she is stable.
How do the QSEN Competencies for quality and safety—specifically, patient-centered care, teamwork and collaboration, and safety—relate to your role as a nurse? (Cite specific examples from the case study.)
How did you evaluate the healthcare provided for your patient, and how did you modify the plan throughout the case study?
How was communication used, and how could it have been enhanced in the case study? (Be specific.)
How were (or weren’t) empathy, compassion, and cultural sensitivity demonstrated with the patient in the case study? What opportunities were there for improvement in these areas?
How would you describe your teamwork with your partner(s). What did you learn from the collaborative experience?

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