Mary Garcia is 34-year-old married woman with one child (a son) that is thee years old. This was a vaginal delivery. She is pregnant with second baby and thinks she is 34 weeks pregnant. She weighs 220 pounds. Patient has scant prenatal care. Her husband brought her in last night because she was dizzy with blurred vision. She states that she “has no pain at this time.” Her temperature 98.8, blood pressure was 150/81, her respirations 34. The patient’s last postprandial glucose test was 193 mg/dl. Patient’s fasting glucose was 149 mg/dl. Her blood pressure was 143/85, respiration 28, and temperature 98.8

QUESTION

OB Case Study Week 1

Houston Baptist University

NURS 4434 Care of Childbearing Family

Antepartum Care Situation

Learning Objectives: After careful reading of narrative and supporting data student will construct an Antepartum Care Worksheet

1. Interpret provided blood test results; Pre-shift report, Reason for hospitalization; Discussion of medical diagnosis; discussion of obstetric and pregnancy history; Fetal monitoring; and Maternal vital signs.
2. Discuss family configuration; cultural/spiritual assessment, and financial/emotional health.
3. Prioritize Problem List/Nursing Diagnosis, R/T and AEB — three for mom and three for baby.
4. Review and record medications including drug name, dose, side effects (look-up) on Scheduled Medication Worksheet.
5. Compose detailed Care Plan for mother including: Highest Priority Nursing DX; Plan; Intervention; Rationale; Evaluation; Skills Used; Legal Ethical Issues; and Safety Concerns
6. Compose detailed Care Plan for infant including: Highest Priority Nursing DX; Plan; Intervention; Rationale; Evaluation; Skills Used; Legal Ethical Issues; and Safety Concerns
7. Present Nursing Skills; Your Strengths; What Opportunities for improvement there may have presented to you in this situation.

CASE STUDY

After meeting with course instructor at 0630 on 3/16/20 you proceed to meet the charge nurse who then assigns you Tarka RN. Nurse Tarka takes you to room 564 to meet client Maria Garcia.

Mary Garcia is 34-year-old married woman with one child (a son) that is thee years old. This was a vaginal delivery. She is pregnant with second baby and thinks she is 34 weeks pregnant. She weighs 220 pounds. Patient has scant prenatal care. Her husband brought her in last night because she was dizzy with blurred vision. She states that she “has no pain at this time.” Her temperature 98.8, blood pressure was 150/81, her respirations 34. The patient’s last postprandial glucose test was 193 mg/dl. Patient’s fasting glucose was 149 mg/dl. Her blood pressure was 143/85, respiration 28, and temperature 98.8

She is concerned that “she has to go home to take care of her three-year-old son because her husband has to go to work” and her mother (who lives with her) is out of town.

Fetal heart monitoring was reassuring, but ultrasound indicated that the baby may be large for gestational age.

Patient states that “her baby seems to be moving less” and she is afraid that her baby may come early.

Test results

New doctor’s order: Pt. put on a calorie restrictive diet and pre and postprandial blood sugar test. Pt. to monitor her blood pressure. Pt. is instructed to monitor fetal movement. Mary has orders to see her obstetrician next week.

Complete assessment of mother and baby (cite sources).

Care plan for mother and baby.

Prioritize Nursing diagnosis (including R/T and AEB) 3 for both mother and baby.

Cite where you got this information.

ANSWER

Antepartum Care Case Study: Assessment and Care Plan for Mother and Baby

Introduction

In this case study, we will assess the antepartum care needs of Maria Garcia, a 34-year-old pregnant woman, and develop a comprehensive care plan for her and her baby. We will analyze the provided blood test results, review the pre-shift report, discuss the reason for hospitalization, medical diagnosis, obstetric and pregnancy history, fetal monitoring, and maternal vital signs. Additionally, we will explore family configuration, cultural/spiritual assessment, and financial/emotional health. Finally, we will prioritize nursing diagnoses, medications, and create detailed care plans for both the mother and baby.

Assessment of Maria Garcia

Maria Garcia, a 34-year-old married woman, is pregnant with her second baby, currently at approximately 34 weeks of gestation. She has had scant prenatal care and was brought to the hospital by her husband due to dizziness and blurred vision. Maria reports no pain at present, and her vital signs indicate a temperature of 98.8°F, blood pressure of 150/81 mmHg, and respiratory rate of 34 breaths per minute. Her last postprandial glucose test revealed a value of 193 mg/dl, and fasting glucose was 149 mg/dl. She also expresses concern about reduced fetal movement.

Assessment of the Baby

The fetal heart monitoring is reassuring, but the ultrasound suggests that the baby may be large for gestational age. This finding raises concerns about potential complications during delivery.

Blood Test Results:

– Blood type: A+

– Rubella: Immune

– Rh factor: Positive

– HIV: Negative

– Antibody screen: Negative

– RPR/VDRL: Negative

– Hgb: 12.7 g/dl

– Hct: 35.5%

– WBCs: 6.5 x 10^9/L

– Platelets: 204 x 10^9/L

– HbSAg: Negative

– Gonorrhea: Negative

– Chlamydia: Negative

– GBS: Negative

Care Plan for Mother (Highest Priority Nursing Diagnosis)

Nursing Diagnosis: Gestational hypertension related to increased blood pressure readings (R/T pregnancy-induced physiological changes).

Plan

Monitor blood pressure regularly, at least every 4 hours.

 Encourage rest and stress reduction techniques.

 Educate the patient on the signs and symptoms of preeclampsia.

Interventions:

 Obtain accurate blood pressure readings using appropriate techniques.

 Promote a calm and supportive environment.

Provide information on managing stress and relaxation techniques.

Rationale

Regular blood pressure monitoring helps detect any sudden changes or worsening hypertension.

 Rest and stress reduction techniques help manage blood pressure and reduce the risk of complications.

Education empowers the patient to recognize potential signs of preeclampsia, promoting early intervention and prevention of severe complications.

Evaluation

 Blood pressure within acceptable range, without significant increases.

 Patient reports feeling more relaxed and less stressed.

 Patient demonstrates understanding of preeclampsia signs and symptoms.

Care Plan fonale

Continuous fetal heart rate monitoring helps identify signs of distress and guides appropriate interventions.

Decreased fetal movement may indicate compromised oxygenation and requires prompt evaluation.

Additional diagnostic tests provide a comprehensive assessment of fetal well-being.

Evaluation:

 Fetal heart rate and pattern remain within normal range.

No significant decrease in fetal movement.

Diagnostic tests indicate adequate fetal well-being.

Conclusion

In this case study, we assessed the antepartum care needs of Maria Garcia and her baby, prioritized nursing diagnoses for both, and developed comprehensive care plans. By closely monitoring Maria’s blood pressure, educating her about preeclampsia, and promoting relaxation techniques, we aim to manage her gestational hypertension effectively. Additionally, we will continuously monitor the baby’s fetal heart rate, assess for signs of distress, and collaborate with the healthcare team to ensure optimal fetal well-being. By providing evidence-based care and addressing potential complications, we strive to promote positive outcomes for both mother and baby.

References

– Clinical assessment skills for healthcare professionals. (2011). Upper Saddle River, NJ: Pearson.https://bmcmededuc.biomedcentral.com/articles/10.1186/1472-6920-11-78 

– Perry, A. G., Hockenberry, M. J., Lowdermilk, D. L., Wilson, D., & Keenan-Lindsay, L. (2018). Maternal child nursing care. Elsevier Health Sciences.https://books.google.com/books?hl=en&lr=&id=MmdjEAAAQBAJ&oi=fnd&pg=PP1&dq=-+Perry,+A.+G.,+Hockenberry,+M.+J.,+Lowdermilk,+D.+L.,+Wilson,+D.,+%26+Keenan-Lindsay,+L.+(2018).+Maternal+child+nursing+care.+Elsevier+Health+Sciences.&ots=SQgAF9UxjR&sig=U6Xv_OH-9v-xHj_38WiwUkim-FI 

– Ricci, S. S., Kyle, T., & Carman, S. (2019). Maternity and pediatric nursing. Wolters Kluwer.https://books.google.com/books?hl=en&lr=&id=gaYtFuND7VIC&oi=fnd&pg=PA1&dq=-+Ricci,+S.+S.,+Kyle,+T.,+%26+Carman,+S.+(2019).+Maternity+and+pediatric+nursing.+Wolters+Kluwer.&ots=jkWZrhspry&sig=MzREhZi2PEOn7jxhszgYdYWAtec