Subjective: Monica Porter is a 42-year-old African Canadian woman, G2

Subjective: Monica Porter is a 42-year-old African Canadian woman, G2 P1, at 35 weeks gestation. During her first pregnancy, Monica was on labetalol for 9 weeks (33 weeks gestation until 3 weeks post-partum). Monica felt fine until two days ago, when she started experiencing a persistent, severe headache with complaints of diplopia. She has tried acetaminophen and coffee, but neither have given her relief. Yesterday she noticed swelling in her hands, feet, and face. Her physician has decided to admit her for observation. Social: Monica lives at home with her 14-month-old son and elderly mother, whom she is the primary care provider. Monica wants to prolong delivery for another two weeks to maximize her income before going on maternity leave. Objective: Chart View: Assessment BP: 168/94 mmHg HR: 80 beats/min RR: 19 breaths/min T: 37.2 oC Weight: 90 kg (198lb) Height: 5 ft. 6 in Edema: hands, feet, face Deep tendon reflexes: +2, no clonus Urine dipstick: +3 proteinuria Based on Monica’s symptoms and the nurse’s assessment data (above), what do you think is happening to Monica? What additional subjective data questions should the nurse ask the patient? What risk factors predispose Monica to this condition? Based on Monica’s symptoms, it is suspected she is possibly suffering from preeclampsia. Preeclampsia, with or without severe features, is a disorder of pregnancy associated with new-onset hypertension, with accompanying proteinuria, occurring most often after 20 weeks of gestation and frequently near term (Karrar & Hong, 2024). A nurse should assess if there are any other visual problems besides diplopia, such as light sensitivity or blurred vision since this could indicate developing preeclampsia. Furthermore, assess for any stomach pain particularly in the right upper quadrant since this may indicate liver involvement. Additionally, the nurse should assess Monica’s urine output to determine renal function. The nurse should monitor weight changes as this can indicate fluid retention and or worsening edema. Although, nausea and vomiting are more prevalent in the beginning of pregnancy, an occurrence of these symptoms could potentially lead to dehydration and electrolyte imbalance. Monica is prone to preeclampsia due to several factors related to her medical history. Monica developed hypertension during her first pregnancy, in which she used Labetalol, increasing the risk of it recurring in future pregnancies. Obesity is a known risk for preeclampsia as evident by a BMI of 32. Monica is 42, and women greater than 35 are more likely to have pregnancy related problems due to increase in age. African Canadian’s have an increased risk for preeclampsia and, multi-parity or becoming a mother for the second time raises the risk of preeclampsia and other associated issues. /2 marks What lab values would be important to obtain and why? (I feel this section should be more point form) It is important to obtain a full metabolic panel, specifically liver function tests (LFT) (AST&ALT) as this would indicate dysfunction seen in severe preeclampsia or HELLP syndrome. Assessing BUN and creatinine would allow the nurse to determine renal function as preeclampsia could lead to renal damage. Thrombocytopenia can indicate the progression of preeclampsia in HELLP syndrome which would require immediate medical intervention. Hematocrit levels should additionally be checked as high levels would support the diagnosis of preeclampsia. (Or we can word it like this) I prefer this 1 Complete blood count Platelet count: Low platelet count (thrombocytopenia) can indicate severe preeclampsia. Hemoglobin and Hematocrit: These values can help assess hemoconcentration. Liver Function Tests AST and ALT: Elevated levels can indicate impaired kidney function. Coagulation Profile PT, aPTT, and fibrinogen: These tests assess the blood’s ability to clot and can indicate coagulopathy. Uric Acid: Elevated levels can indicate hemolysis, a component of severe preeclampsia. BUN and creatinine: this would allow the nurse to determine renal function as preeclampsia could lead to renal damage. Urinalysis: Proteinuria: the presence of protein in the urine is a possible indicator of preeclampsia and requires further investigation. /2 marks After the nurse notified the physician of Monica’s condition, the physician orders magnesium sulfate. The nurse administers magnesium sulfate and walks into Monica’s room to discontinue her IV and reassess her vital signs. Monica’s vital signs are as follows: T 37.1 oC, P 109 beats/min, RR 7 breaths/min, BP 100/60 mm/Hg, 02 94% on room air. Why is magnesium sulfate the drug of choice in this situation? What vital sign data is relevant that must be recognized as clinically significant to the nurse? Magnesium sulfate acts as a strong anticonvulsant preventing seizures associated with eclampsia and is the preferred medication with this condition. When monitoring vital signs, several considerations need to be made after administering this medication such as decreased respirations which could indicate magnesium toxicity. Elevated levels of magnesium can lead to respiratory muscle weakness, decreased respiratory rate and ineffective breathing. Furthermore, it can attribute to a reduction in muscle reflexes, altered levels of consciousness, renal impairment, and other metabolic imbalances particularly with calcium and potassium leading to more complications. Monica is also slightly tachycardic however this could be a compensatory response to the low blood pressure and effects of the medication. /2 marks The physician discontinues the infusion and orders calcium gluconate. One hour after the calcium gluconate is administered the nurse reassesses Monica and obtains a new set of lab values. Chart View: Assessment BP: 189/91 mmHg HR: 90 BPM, 2+; S1, S2, S3 RR: 18 breaths/min; clear entry bilaterally T: 37.2 oC 02 Sat: 97% RA Severe headache RUQ pain, abdomen guarded and tender on palpation in the mid epigastric area Edema: hands, feet, face Urine dipstick: +3 proteinuria Skin intact, no rashes, normal colour Chart View: Laboratory Values Potassium: 4.6 (3.5-5.0) mmol/L Sodium: 136 (135-145) mmol/L BUN 8.5 H (2.5-8.0) mmol/L Creatinine 155 H (50-90) ??mol/L AST: 70 H (0-35) U/L ALT: 62 H (3-36) U/L Total bilirubin: 29 H (<26) ??mol/L WBC 8.7 (3.6-11.0) x 109/L RBC 4.79 (3.70-5.00) x1012/L HBG 60 (115-150) g/L HCT 0.44 (0.345-0.450) L/L MCV 86.0 (80.0-99.0) fL MCH 28.6 (27.0-33.0) pg MCHC 333 (320-360) g/L RDW 13.2 (12.0-15.0) % Platelet Count 90 L (140-400) x109/L MPV 15.5 (9.0-14.0) fL Urine: ++ Proteinuria What assessment data is relevant that must be recognized as clinically significant to the nurse? Based on the clinical symptoms and lab values, what does the nurse suspect is happening to Monica? Please provide rationale based on the lab values. Relevant Data: Severe headache, RUQ pain, Bp189/91mmHG, S3 heart clinically significant as it could indicate heart failure further worsening her edema. Proteinuria ++, Creatinine 155, Low Hemoglobin 60, Mean platelet volume 15.5, AST (70) ALT (62), Bilirubin (29) Low platelet count 90L suggests HELLP syndrome, which is a severe form of preeclampsia characterized by hemolysis, elevated liver enzymes and thrombocytopenia. These lab values may indicate Monica's problem is getting worse and immediate action to safeguard the health of Monica, and her baby is needed. /3 marks Based on Monica's suspected condition, what interventions exist for this patient? Based on the suspected condition the interventions that exist include monitoring Monica's blood pressure, bed rest, and administration of antihypertensives as ordered to better control her blood pressure to reduce the chances of organ damage and or stroke. The nurse should continue to monitor for weight gain, worsening edema, further changes to heart and lung sounds to monitor for fluid volume excess. The nurse should also assess for changes in level of consciousness and deep tendon reflex responses to assess for any neurological deficits. The nurse should also monitor fetal movement via continuous fetal monitoring to assess any changes or distress the baby may be experiencing. If the mother or the fetus's condition worsens the healthcare team may need to prepare for an early delivery of the baby, this decision would be made collaboratively with the patient to protect both Monica and her baby. Possibly give dexamethasone to promote fetal lung development prior to delivery. /1 mark After considering the trend in Monica's condition and the health of her baby, the care team decides that delivery is the safest choice. Monica delivers a healthy baby via cesarian section and is discharged home after 72-hours. Identify one potential barrier to a successful discharge and one strategy you will teach Monica to ensure successful self-management/treatment adherence prior to discharge? Potential barriers consist of lack of support at home as she is the primary caregiver for her elderly mother and young son. Monica may find it challenging to focus on her recovery and appropriately manage any unresolved preeclampsia-related health issues. To address this issue may include scheduling follow-up treatment with a home health nurse or social worker who may provide postpartum support and assistance with daycare obligations. This plan can assist Monica in her recovery and ensure she receives the information required to practice self-management after she is discharged from the hospital. /2 marks What interdisciplinary team members should be involved in Monica's case to ensure optimal recovery and why (e.g., does your patient require a home assessment [OT])? The team should include obstetricians experienced in high-risk pregnancies to oversee the ongoing management of any complications that arise from preeclampsia. Nurses who specialize in high-risk obstetrics will play a role in providing Monica with postpartum care education and status updates throughout her hospital stay. Social work should also be involved to assist with resource coordination and provide any necessary support services to address any socioeconomic issues that could influence Monica's health outcomes. Occupational Therapists could assist in ensuring Monica is supported post discharge by recommending equipment that supports function and teaching optimal positioning having had surgery. /1 mark Identify 2 key local community services or resources that should be coordinated for Monica to ensure optimal recovery. Explain the rationale for your chosen resources. The following resources are community services that should be coordinated for Monica to ensure optimal recovery. Monica has many concerns, and we believe these combined resources will help best facilitate the overall health of Monica and her baby. Bayshore Home Health- Windsor/Essex This multifaceted home agency service provides nursing as well as personal care services that could be a major benefit to Monica once discharged from hospital. Personal care services could aid with caring for Monica's elderly mother, providing respite during her recovery. Additionally, nursing care support is available for post-surgical care such as pain management, wound care and follow-up teaching and management of blood pressure, and follow-up teaching and management of blood pressure. Windsor/Essex County Health Unit- La Leche League (lactation consultant) Lactation consultants provide health teaching and make recommendations to help mothers experiencing breastfeeding issues such as painful and incomplete latching, breast engorgement, and breastfeeding positioning. Monica has many concerns, and we believe these combined resources will help best facilitate the overall health of Monica and her baby. Pharmacy Pharmacists are often more accessible. Their scope of practice has expanded, allowing them to prescribe medications for minor ailments. In addition, the delivery service can be helpful during her recovery time. The pharmacy can also help to reduce medication errors by providing medication in blister packs. This allows for convenient administration when caring for her elderly mother.

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