Post Partum HESI Case Study free essay sample

The lack of sensation below the waist caused by the residual effects of epidural anesthesia does not pose any real threat of infection, because epidural side effects are unrelated to the mechanisms of infection transmission or development. B) Risk for injury. Epidural anesthesia causes temporary loss of voluntary movement and muscle to get out of bed on her own, because her legs will be unable to sustain her weight. The nursing priority is to ensure her safety by implementing use of all four side-rails and instructing her to not get out of bed for the first time without assistance.C) Impaired physical mobility. Marries impaired physical mobility is temporary and is not likely to cause complications resulting in long-term immobility. D) Altered urinary elimination. While the epidural anesthesia may temporarily inhibit Marries ability to void voluntarily, this is usually resolved within six hours. Marie should be monitored for bladder fullness during the period that she is unable to sense the need to void, but this concern is secondary to client safety. We will write a custom essay sample on Post Partum HESI Case Study or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page 3. What is the priority nursing action to address Marries needs related to the repair of her 4th degree perinea laceration?A) Provide prescribed oral pain medication and tool softener. Feedback: INCORRECT Marie has no sensation below her waist because of the residual effects of the epidural anesthesia. She does not need pain medication at this time. A stool softener is usually administered within 24 hours of delivery, but it is not a priority at this time. B) Teach proper and frequent use of the pert-bottle. It is important for the nurse to instruct Marie in measures to prevent infection, such as frequent and proper perinea hygiene techniques during the postpartum period.However, this teaching is not a priority at this time. Marie is exhausted (therefore not exceptive to teaching), and she is unable to get up to the bathroom to void (epidural anesthesia). The more appropriate time to teach use of a pert-bottle is while assisting Marie after she is able to get up and void in the bathroom. C) Apply perinea ice packs consistently for the first 24 to 48 hours. Feedback: CORRECT Topical perinea ice packs cause local vasoconstriction, resulting in decreased swelling and tissue congestion, as well as promoting comfort.The application of ice that the tissue is most vulnerable to swelling resulting from the trauma. D) Encourage warm sits baths 2 to 3 times daily. Soothing, warm sits baths should be encouraged, because they increase circulation to the site and promote healing. However, sits baths are not encouraged until the 2nd or 3rd postpartum day, after the swelling has decreased. Promotion of increased circulation prior to this time will result in increased amounts of swelling, tissue congestion, and pain. Early detection of, and intervention for, postpartum complications promotes positive client outcomes. Postpartum protocol requires that the nurse assess Marries vital signs, funds, perineum, vaginal bleeding, pain, leg movement, and IV every 15 minutes for the first hour and then every hour for the next three hours. 4. Considering Marries history, which postpartum complication is she most at risk for? A) Deep vein thrombosis. Venous thrombosis forms in response to inflammation in the vein wall as a result of venous stasis.Factors contributing to the development of deep vein thrombosis in the postpartum client include increased amounts of certain blood clotting factors, obesity, increased maternal age, high parity, prolonged inactivity, anemia, heart disease, and varieties. Marries history does not indicate any risk factors for deep nine thrombosis. B) Substitution. Substitution occurs when the uterus fails to follow the normal pattern of involution, but instead remains enlarged. It is caused by placental fragments or infection. The labor and delivery nurse stated that Marie delivered the entire placenta, I. E. , no fragments were retained in the uterus.Marries history does not indicate any risk factors for substitution. C) Endometriosis. Endometriosis is a uterine infection, one of four types of puerperal (of or pertaining to contribute to increased risk for puerperal infection which are: poor nutritional status, anemia, vaginal infection with group B streptococcus, and diabetes. D) Hemorrhage. Postpartum hemorrhage indicates loss of greater than 500 ml of blood after the end of the third stage of labor. Causes of early postpartum hemorrhage include uterine atone (relaxation of the uterus), laceration of the genital tract, and retained placental fragments.Factors in Marias history that contribute to the potential for hemorrhage include: overprotection of the uterus due to a large infant, the trauma of a forceps delivery, a prolonged labor, and the use of extinction. Postpartum Crisis Fifteen minutes after the initial assessment, the nurse finds Marie disoriented and lying on her back in a pool of vaginal blood, with the sheets beneath her saturated with blood. 5. What is the priority nursing action? A) Take vital signs. If the nurse takes the vital signs first, time will be lost while the client continues hemorrhaging. B) Check the bladder.Several interventions should be implemented simultaneously. Bladder distention is a common problem that can impede uterine contraction and predispose the client to bleeding, but another action should be implemented immediately. C) Massage the funds. Since a boggy funds is the most likely reason for this clients hemorrhaging, massaging the funds is the most important intervention. The nurse should also call for assistance due to the amount of blood that has pooled under the client. This is an important action since the client is hemorrhaging and is probably humiliatingly unstable. 6.What is the best method for the nurse to use to obtain immediate assistance? A) Call for help from the doorway of the clients room. Although staying with the client is important during a crisis, it is not appropriate to hoot in the hallway. This could alarm other clients, and it is not the best way to summon help. B) Go to the nurses station to notify the charge nurse. The nurse should never leave a critical clients bedside for any reason. The first rule during a crisis is to stay with the client. C) Activate the priority call light from the bedside. The priority call light signals to the entire nursing unit that a client is in crisis.All personnel available will respond to the distress signal. D) Telephone the healthcare provider from the clients room. Feedback: INCORRECT The healthcare provider needs to be notified as soon as possible, but not without collecting data first. The healthcare provider will have questions regarding the clients status. Anticipating and collecting the necessary data will facilitate effective communication with the healthcare provider. The nurse has requested assistance and personnel are on their way. While waiting for help to arrive, what is the next priority action? A) Apply oxygen.Applying oxygen is important to improve the clients oxygenation, but it is of less priority than addressing the cause of the hemorrhage. B) Increase the IV infusion rate. Greater fluid volume administered intravenously is an important lifesaving action, but this is of less priority than addressing the cause of the hemorrhage. C) Obtain vital signs. It is important to assess vital signs, but this is of less priority than addressing the cause of the hemorrhage. D) Assess for bladder distention. The client is two hours post delivery with an IV infusing at 125 ml/hour, which can contribute to dieresis.A distended bladder impedes uterine contraction and contributes to excessive bleeding. After the funds is massaged, the bladder should be checked for distention. The charge nurse, two staff nurses, and an unlicensed assisting personnel (ASAP) rush in to assist the nurse with Marie. 8. Which task is best delegated to the PAP during this crisis? A) Obtain the vital signs and 02 saturation. Obtaining vital signs and pulse geometry are within the scope of practice for the PAP, and the nurse should interpret these findings as indications of hypoglycemia due to blood loss, and should also report the findings to the healthcare provider.B) Change the bed linens and bathe the client. The client is lying in a pool of blood. So at some point, the linens will need to be adhered and weighed to estimate blood loss, and the client will need to be bathed. Priority at this time. C) Start 02 per nasal canal. The I-JAPE can collect the equipment but the nurse should initiate 02 administration. D) Bring IV fluids and supplies from the supply room. It will be difficult for a PAP to know exactly which type of IV fluid to obtain. Since there are many sizes and types of fluid to select from in the supply room, there is a greater chance for delay and error if the PAP is sent. 0. /1 . 0 The healthcare provider is notified that Marie is hemorrhaging and has an estimated load loss of 1,200 ml since delivery. The clients blood pressure is 70/40, pulse 120, respirations 28, and 02 saturation 73%. The healthcare providers prescriptions include stats extinction 10 units in each liter of normal saline to infuse at 40 militants (ml)/minute. The healthcare provider also prescribes 0. 2 MGM interrogatively emulate (Mothering) IM to be given immediately. The vial of extinction is labeled 10 units/ml. 9. How many ml of extinction should the nurse draw up in the syringe to inject into the 1000 ml bag of normal saline?A) 0. 04 ml. This answer is incorrect. Please try again. C) 10 mi. D) 1 mi. The healthcare provider prescribed 10 units in 1,000 ml of NSA. The vial contains 10 The extinction must be administered via an IV infusion pump. 10. What is the flow rate needed to deliver 40 ml/minute? A) 24 ml/her. B) 40 ml/her. C) 4 ml/her. D) 240 ml/her. Drip concentration = 10,000 ml/1,OHO ml. 40 ml/1 min x 60 min/l her=240 ml/1 her. 240 earn ml = 10,000 mum/l,oho ml 10,oho x = x = 240 ml/her. Initial Stabilization reassesses the client. 11. Which finding is most indicative that the medication is reaching a therapeutic level?A) 02 saturation 85%. This improvement in 02 saturation primarily indicates that the administration of supplemental oxygen is effective, not the extinction. B) Blood pressure 74/44. An increase or improvement in the blood pressure indicates that the fluids being administered are treating the hypoglycemia, but it does not necessarily mean that the extinction is effective. C) Firm funds. The desired therapeutic effect of extinction is to cause potent and selective stimulation of uterine smooth muscle. A firm funds indicates uterine contraction during the postpartum period, which is important to prevent further hemorrhage.D) Heart rate 94. A decrease in the heart rate indicates that the fluids being administered are helping maintain fluid volume, but this is not the best indicator of the medications effectiveness. Postpartum hemorrhage is designated as blood loss in excess of 500 ml within the first 24 hours of delivery. 12. Considering the clients history, what etiology is most likely? A) Uterine atone. The clients history revealed a prolonged labor (muscle fatigue) and a large baby (uterine overprotection). These are both frequent causes of uterine atone.The initial report received from the labor and delivery nurse was that the full placenta was delivered. C) Perinea laceration. The laceration edges were well approximated and intact. D) Coagulate. Acquired coagulate may be secondary to upperclassman, sepsis, or significant hemorrhage during delivery. The clients history did not include these problems. Marie is pale, weak, and anxious, but no longer disoriented. Her funds is firm and is 1 CM above the umbilicus. She is receiving 02 per nasal canal at 4 liters/minute and has an 02 saturation of 88%. Her vital signs are: BP 74/44, pulse 116 and aspirations 26.