CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) “Gestational diabetes mellitus (GDM) is an impaired tolerance to glucose with the first onset or recognition during pregnancy. The ideal blood glucose level during pregnancy should range between 60 to 99 mg/dL before meals or fasting, and less than or equal to 120 mg/Dl.2 hr. after meals. Findings of diabetes mellitus can disappear a few weeks following delivery. However, approximately 50% of clients will develop type 2 diabetes mellitus later in life.” (Holman et al., 2019) DIAGNOSTIC TESTS (REASON & RESULTS) PATIENT INFORMATION EXPECTED PHYSICAL FINDINGS None of the following test were observed in the vsims – no results were given. • Glucose screening test/1-hr glucose tolerance test: 50g oral glucose load, followed by plasma glucose analysis 1 hr later performed at 24 to 48 weeks of gestation; fasting not necessary; a positive blood glucose screening is 130-140 mg/dL or greater; additional testing with a 3-hr oral glucose tolerance test (OGTT) is indicated.” • Presence of ketones in urine (Holman et al., 2019) Amelia Sung, Female Adm DX: labor induction due to gestational diabetes DOB: 7/11/1984 (36y) Height: 157 cm Weight: 83 kg Allergies: Shellfish Adm on: 8/15/2020 • “Hypoglycemia: nervousness, headache, weakness, irritability, hunger, blurred vision.” • “Hyperglycemia: polydipsia, polyuria, nausea, abdominal pain, flushed dry skin, fruity breath.” • Shaking • Rapid pulse • Clammy pale skin • Excess weight gain during pregnancy (Holman et al., 2019) ANTICIPATED NURSING INTERVENTIONS • Monitor clients blood glucose • Monitor vital signs • Monitor the fetus • Educate patient about lifestyle changes following delivery. • Vaginal examination • Provide emotional support for the patient. • Assess urine for the presence of ketones (Holman et al., 2019) INTRODUCTION Your name, position (RN), unit you are working on RN, Labor and Delivery Unit SITUATION Patient’s name, age, specific reason for visit I am caring for Amelia Sung, she is a 36-year-old female patient who was admitted yesterday with labor induction due to her gestational diabetes. BACKGROUND Patient’s primary diagnosis, date of admission, current orders for patient The patient was diagnosed with labor induction due to gestational diabetes, she was admitted on 08/17/20. Assessment Current pertinent assessment data using head to toe approach, pertinent diagnostics, VS Patients vital signs were all within normal limits. FHR was 120 with moderate variability and early decelerations since patient started pushing. She asked for an epidural and we gave that to her. She fully dilatated 3 hours ago and started pushing. Currently the baby’s head is starting to crown. RECOMMENDATION Any orders or recommendations you may have for this patient I recommend continuous monitor for the patient and to prepare the patient for a cesarean delivery. You will need to consult the surgery unit, NICU and anesthesia. Continue to monitor her vital signs and ensure patient is comfortable. PATIENT EDUCATION WORKSHEET: NAME OF MEDICATION: Oxytocin CLASSIFICATION: oxytocics PROTOTYPE DRUG: Oxytocin SAFE DOSE/DOSE RANGE/SAFE ROUTE: IV 10 units infused at 20-40 mU/min PURPOSE FOR TAKING THIS MEDICATION: to induce labor PATIENT EDUCATION WHILE TAKING THIS MEDICATION: • “Advise patient to expect contractions similar to menstrual cramps after administration has started.” • Advise patient to remain in bed. CLINICAL WORKSHEET Date: 08/17/20 Student Name: Assigned Vsim: PT Initials: AS Diagnosis: Labor induction due to gestational diabetes HCP Dr. Jeff Smith Isolation: N/A IV Type: Peripheral IV Critical Labs: 94+ mg/dl O+ blood Other Services: NICU Age: 36 Length of stay: unknown Consults: Health care provider NICU Surgery unit Fall risk: Bed rest Location: Left forearm M/F Female Allergies: Shellfish Transfer: N/A Fluid/Rate: Lactated ringers at 125 mL/hr. Consults needed: Health care provider NICU Code Status: Full code- fall risk Surgery unit Why is your patient in the hospital? (answer in your own words and include the history of the present illness): Amelia Sung was hospitalized for the diagnosis of labor induction due to gestational diabetes. Health history/ comorbidities that relate to this hospitalization: • Patients first born was delivered vaginally 3 years and 3 months ago weighing 7lbs and 6 oz and 55cm in length. • Gestational diabetes Shift goals or Patient educational needs: 1. Apply oxygenation with a nonrebreather mask set to 100% for non-reassuring FHR. 2. Check vital sings frequently. 3. Position into McRoberts position. 4. Educate the patient on importance of staying in bed. 5. Administer appropriate medications. Path to Discharge: • Patient delivers baby safely and is cleared to return home. Path to Injury or Death: • Shoulder dystocia • Fetal death • Postpartum hemorrhage Alerts: What are you on alert for with this patient? What assessments will you focus on for this patient? (3) (how to identify signs & List complications that may occur related to DX, procedures, comorbidities What nursing or medical interventions may prevent these complications? (4) (3) (signs/symptoms) symptoms) (3) Non-reassuring FHR Attach a continuous FHR monitor. Fetal asphyxia Administer oxygen – 100% with a nonrebreather mask. Shoulder dystocia delivery Abdominal palpation • Determine fetal position, weight and measure fundal height. Postpartum hemorrhage Monitor vital signs Polyphagia, polydipsia, polyuria Glucose testing • Polyphagia- does the patient have an increased appetite? • Polydipsia- is the patient thirstier? • Polyuria- has patient been urinating frequently? Preterm birth Reposition patient- McRoberts position Management of care: What needs to be done for this patient today? (6) Priorities for managing the patient’s care today (4) (TASKS) What aspects of the patient’s care can be delegated? (can TASK be delegated) Y/N Who can perform the delegated tasks? (list who can be delegated) Prepare patient for birth- C-section Provide support for the patient as she may be nervous/uncomfortable. Vital signs LVN/LPN/Tech Administer oxygen – 100% with a nonrebreather mask. Continuous monitoring of FHR and mothers’ vital signs. Emotional support Position patient into McRoberts position Contact NICU and surgeon to prep for C-section Educate patient on the need to stay in bed Medication administration Administer appropriate medications Prepare the emergency team Nursing Diagnosis #1 Nursing Goals & Expected Outcomes Nursing Interventions Rationale Response to Interventions What 2 nursing -Discuss evaluation List a minimum of 2 Give rational for Summarize patient’s priorities guide your plan of care and expected outcome of each nursing intervention -Include 2 patient goals per nursing diagnosis (short & long term) nursing interventions per goal diagnoses, goals, interventions Cite all references and sources used in APA format response to interventions 2 nursing diagnoses; 2 goals per diagnosis (short & long); 2 interventions per goal (4 per diagnosis) Risk for Maternal Injury related to changes in diabetic control Short: “patient will be free of signs and symptoms of diabetic ketoacidosis (fruity- scented breath, excessive thirst, frequent urination, weakness, confusion)” Long: “Patient will maintain normoglycemia” (Martin, 4 Gestational Diabetes Mellitus Nursing Care Plans 2019) 1. a) “Identify epoxides of hyperglycemia” b) “Assess and monitor for sings of edema” 2. a) “Monitor serum glucose level at each visit.” b) “Monitor for total protein, excretion, creatinine clearance, BUN, and uric acid levels.” (Martin, 4 Gestational Diabetes Mellitus Nursing Care Plans 2019) 1. a) “Diet and/or insulin regulation is necessary for normoglycemia, especially in second and third trimesters, when insulin requirements usually doubled.” b) “Because of vascular changes, the diabetic client is prone to excess fluid retention and PIH. The severity of vascular changes prior to pregnancy influences the extent and time of onset of PIH.” 2. a) “Detects impending ketoacidosis; helps determine times of day during which the client is prone to hypoglycemia.” b) “Progressive vascular changes may impair rental function in clients with severe or long- standing diabetes.” (Martin, 4 Gestational Diabetes Mellitus Nursing Care Plans 2019) Patient understood and explained the reasonings for monitoring and making changes in diabetic control. Nursing Diagnosis #2 Nursing Goals & Nursing Rationale Response to Expected Outcomes Interventions Interventions What 2 nursing priorities guide your plan of care -Discuss evaluation and expected outcome of each nursing intervention -Include 2 patient goals per nursing diagnosis (short & long term) List a minimum of 2 nursing interventions per goal Give rational for diagnoses, goals, interventions Cite all references and sources used in APA format Summarize patient’s response to interventions 2 nursing diagnoses; 2 goals per diagnosis (short & long); 2 interventions per goal (4 per diagnosis) “Risk for fetal injury related to elevated maternal serum blood glucose levels and changes in circulation.” (Martin, 4 Gestational Diabetes Mellitus Nursing Care Plans 2019) Short: “Fetus will normally display reactive normal stress test and negative OCT and CST.” Long: patient serum blood glucose levels will normalize (Martin, 4 Gestational Diabetes Mellitus Nursing Care Plans 2019) 1. a) “Monitor for signs of PIH (edema, hypertension, proteinuria.” b) “Monitor fundal height each visit.” 2. a) “Assess fetal movement and fetal heart rate each visit as indicated. Encourage the client to periodically record fetal movements beginning about 18 weeks’ gestation, then daily from 34 weeks’ gestation on.” b) “Monitor urine for ketones. Note for fruity-breath” (Martin, 4 Gestational Diabetes Mellitus Nursing Care Plans 2019) 1. a) “About 12-13% of diabetic individuals develop hypertensive disorders owing to cardiovascular changes associated with diabetes. These disorders negatively affect placental perfusion and fetal status.” b)” Useful in identifying abnormal growth pattern (macrosomia or IUGR, small or large gestational age (SGA/LGA) 2. a) “Fetal movement and fetal heart rate may be negatively affected when placental insufficiency and maternal ketosis occur.” b) “Irreparable CNS damage or fetal death can occur as a result of maternal ketonemia especially in the third trimester.” (Martin, 4 Gestational Diabetes Mellitus Nursing Care Plans 2019) FHR is normalized Maternity Case 3: Amelia Sung Documentation Assignments 1. Document the fetal status and the progression of Ms. Sung’s labor from the time you took over care of Ms. Sung until the provider takes her to the delivery room. The patient’s vital signs were within normal limits as follows- HR 89, pulse present, BP 140/82, respirations 17, SpO2 97%, temp 37 and FHR 121. When I entered the patients room the head was starting to crown. I preformed my assessments and then we started to deliver the baby. Her chest was moving equally and her skin was normal elasticity. I prepared the delivery table, educated the patient and then encouraged her to start pushing. I attached a 100% oxygen with a nonrebreather mask per drs. Orders. The NICU and charge nurse were called to assist. I continued encouraging the patient and then positioned the patient into McRoberts position. The secondary nurse applied suprapubic pressure and the baby’s neck and shoulders were delivered then the baby was delivered. The baby was then handed to the charge nurse for further examination. 2. Document the essential events related to the time of birth, including the activities and interventions from the time of crowning to the complete expulsion of the fetus. The baby’s head was crowing at 2:52, a virginal exam was performed at 5:29, the bassinet was prepared and I checked for the presence of the step stool at 6:51, I then prepared the delivery table at 6:59, I started instructing the patient to push at 7:47, the baby’s head was delivered at 8:49, The baby’s head was retracting at 10:51, I positioned the patient in McRoberts position at 11:11, The babies shoulders were delivered at 11:55, at 12:10 the baby was delivered. 3. Document the application of suprapubic pressure and the response and outcomes. I applied suprapubic pressure at 11:15, the shoulders were delivered at 11:55, then the baby was born at 12:10. The pressure helped to guide the baby out of the mother. 4. Document your communications with the neonatal intensive care unit (NICU) about the impending birth. I called the NICU at the beginning of the simulation because we knew of the possible risk for shoulder dystocia. The NICU and charge nurse were both called to help delivery the baby. Maternity Case 3: Amelia Sung Guided Reflection Questions Opening Questions How did the simulated experience of Amelia Sung’s case make you feel? Once I ran through the simulation once and got an idea of the task I needed to complete I felt comfortable. Describe the actions you felt went well in this scenario. I felt I was able to encourage the patient well in this scenario. Scenario Analysis Questions1 EBP What risk factors specific to shoulder dystocia were identified in Amelia Sung’s case? The baby’s head was delivered without the shoulders which is a key indication of shoulder dystocia. PCC/I Prioritize your nursing actions for Amelia Sung based on your assessment. I should have called the NICU and charge nurse earlier in the simulation and I should have applied the nonrebreather oxygen mask right after checking vital signs. EBP List potential problems for Amelia Sung and her baby related to the shoulder dystocia. Maternal obesity and diabetes. There is a risk for postpartum hemorrhage because of the need of manipulation. T&C List the interprofessional health care team that should be involved in Amelia Sung’s case. NICU and charge nurse. S/QI/I Consider what points might be included in a safety checklist for shoulder dystocia. High maternal birth weight, diabetes, more than 42 weeks of gestation. Concluding Questions Reflecting on Amelia Sung’s case, were there any actions you would do differently? Explain. I would have called for assistance earlier in the simulation and applied the nonrebreather face mask after taking initial vital signs. Describe how you would apply the knowledge and skills that you obtained in Amelia Sung’s case to an actual patient care situation. I would do the same steps I did in this simulation taking care of a patient in real life. 1 The Scenario Analysis Questions are correlated to the Quality and Safety Education for Nurses (QSEN) competencies: Patient- Centered Care (PCC), Teamwork and Collaboration (T&C), Evidence-Based Practice (EBP), Quality Improvement (QI), Safety (S), and Informatics (I). Find more information at: References:
