Olivia Jones Preeclampsia Case Study

Olivia Jones Preeclampsia Case Study Clinical Worksheet Date: 4th June 2020 Student Name: Adedayo Helen Temitope Assigned VSim: Olivia Jones Initials: Age: 23 M/F: Female Code Status: Diagnosis: severe preeclampsia Length of stay: 2 hours Allergies: None HCP: Yes Consults: Recommende d Isolation: No Fall Risk: Moderate Transfer: Bed rest / bathroom priviledges IV Type: Lactated Ringer Location: Labor and delivery unit Fluid/Rate: 125 mL per hour continuous or 500ml IV bolus for nonreassuri ng fetal heart rate pattern Critical Labs: BUN, Creatinine, Triglyceride, LDH Other Services: Hypoxemia Consults needed: Yes Why is your patient in the hospital (Answer in your own words and include the History of Present Illness)? high blood pressure, unrelieved headache even with acetaminophen, visual changes, chest tightness nausea and vomiting, protein in urine, increased weight gain and generalized swelling noted in face and lower extremities Health History/Comorbidities (that relate to this hospitalization): N/A Shift Goals/ Patient Education Needs: Patient education needed on the importance of bed rest, call light use/signaling for help, NPO until serum lab result is received, provision and suggestion of diversional activities while on bed rest, information on tests and procedures to evaluate maternal-fetal status, e.g laboratory tests, sonogram, NST, Encouraging the support of family or friends while on bed rest Path to Discharge: fetal heart rate within normal range, no evidence of pulmonary edema, adequate urine output, no seizure activity, expresses concern for self and the fetus, maintaining bed rest and pursuing diversional activities, Blood pressure and other vital signs within parameters of plan of care and stable. Path to Death or Injury: Abruptio placentae, DIC, HELLP syndrome, maternal or fetal death, hypertensive crisis, pulmonary edema, oliguria, thrombocytopenia, hemorrhage, blindness, fetal intolerance of labor, hypoglycemia, hepatocellular dysfunction, prematurity Alerts: What are you on alert for with this patient? (Signs & Symptoms) 1. Elevated BP 2. Proteinuria 3. increased serum creatinine 4. hyperreflexia 5. persistent epigastric pain 6. low platelet count What Assessments will focus on for this patient? (How will I identify the above signs & Symptoms?) 1) lab result on urine dipstick 2) Serum Creatinine and BUN result 3) vital signs assessment 4) persistent headache, visual disturbances, altered level of conciousness What nursing or medical interventions may prevent the above Alert or complications? 1) Bed rest 2) Maintaining fluid balance Management of Care: What needs to be done for this Patient Today? 1) Delivery of baby if uncontrolled hypertension, eclampsia, pulmonary edema, compromised renal function Priorities for Managing the Patient’s Care Today 1) Maintaining fluid balanc 2) Promoting adequate tissue perfusion. 3) preventing injury.