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Patricia, Preeclampsia

Diagnosis

Preeclampsia

Case Summary

27-year-old woman presenting with persistently elevated BP, headache, visual changes and edema.

Clinical Findings

Persistently elevated BP
Headache
Visual changes
Pitting edema to knees bilaterally
Mild epigastric pain
Brisk reflexes
Positive clonus

Assessment

General Assessment

Take vitals and repeat blood pressure as per protocol
Commence EFM monitoring
Document maternal vitals
Define presenting complaint and timescales
Determine current and previous obstetric history
Take medication and allergy history
Perform basic physical exam, including cardiac and lung exam
Assess degree of edema
Perform palpation for uterine height and fetal lie

Preeclampsia Assessment

Level of consciousness
History of visual changes
History of headache
Deep tendon reflexes
Check for clonus
History of epigastric or RUQ pain

Initial Investigations

Perform and interpret EFM
Take blood tests including AST/ALT ratio
Take urine sample, including P/C ratio
Monitor fluid input/output

Management

Insert IV access
Commence IV saline at 25ml/hr
Give Magnesium Sulfate as prescribed
Give analgesia (acetaminophen) as prescribed
Position patient on her left side

Non-technical Skills

Make rational, timely clinical decisions
Effectively communicate with patient and team
Maintain patient safety and comfort
Apply clinical knowledge and adapt to changes in patient condition
Appropriately utilize other team members
Escalate and refer appropriately

 

 

Related Concepts – In this section please identify and document the main concept of the scenario and then identify and discuss how four other concepts connect to and are impacted by the main concept and how they relate to your patient. (Total of five concepts should be discussed.)
Think about and explain how alterations in the main concept would affect other concepts.
Think about and explain how alterations in other concepts would affect the main concept.
Example-main concept of tissue integrity; if tissue integrity is altered/impaired what would be the impact on other concepts such as nutrition, mobility, elimination, perfusion, thermoregulation OR if there is an alteration in nutrition, mobility, elimination, perfusion, or thermoregulation how would that impact tissue integrity?
Related Assessments – In this section, explain five assessments needed to find and/or rule out alterations with the main concept and provide rationale. Relate these assessments to your patient. Provide assessment data from the patient in the OMS scenario.
Example – main concept of tissue integrity; wound assessment to include location, color, size, shape, odor, and drainage. Report your assessment findings-the patient has a 2cm oval wound on the L heel. The wound is red in color, has no odor, and is producing a scant amount of serous drainage. The wound edges are defined, and the surrounding tissue is pink and warm with no edema.
Related Nursing Interventions – In this section, document Five independent nursing interventions needed to care for your patient related to alterations of the main concept and provide rationale. Independent nursing interventions are those that do not require a provider order.

An intervention is defined as “any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes” (Butcher, Bulechek, Docterman, & Wagner, 2018, p.xii).

SCIENCE
HEALTH SCIENCE
NURSING
BSN 346

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