Growing Family Clinical Case Study

NURS 333 - Clinical Management of the Growing Family

Purpose of Assignment
The purpose of this paper was to conduct an in-depth assessment of a childbearing
woman and her family to plan specific nursing care, based on nursing research and AWHONN
Standards of Care. This assessment includes physiological, psychological, social, cultural, and
environmental influences pertaining to the client and her family relating to preconception,
conception, antepartum, intrapartum, postpartum, and neonatal care.

Student Approach to Assignment

The patient I chose for this assignment was a postpartum patient with multiple health
risks, including preeclampsia. She required continued monitoring after delivering a set of twins.
Through caring for this patient, I attained a strong foundation in maternal and neonatal nursing.

Reason for Inclusion of the Assignment in the Portfolio

This assignment is included in the portfolio since it highlights my understanding of
Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) standards of care.
It also displays the holistic care I provided to a postpartum patient with health challenges that
affected her pregnancy and postpartum period.

 Critical Thinking
 Uses decision-making skills in making clinical or professional judgments.
 Example: In this case study, I used the AWHONN Standard of Care to formulate
nursing diagnoses based on analyzing assessment data and identifying abnormal data.
On reviewing my patient's data and visiting her in postpartum care, my priority
nursing diagnosis is Fatigue related to stressors of her high-risk pregnancy and her
history of anxiety and depression as evidenced by my patient's report of feeling tired,
her inability to get out of bed, and her increased rest requirements. This is the priority
nursing diagnosis because it contributes to my second diagnosis of Impaired Physical
Mobility because my patient has not been able to get out of bed due to her fatigue.
This also contributed to my other diagnoses such as of Risk for Falls related to the
magnesium sulfate in her system since my patient felt dizzy when attempting to sit up
in bed. Also, since she has not been able to walk to the infant special care unit to
breastfeed her son, another diagnosis is Interrupted Family Processes due to being
limited from bonding with her son because of the separation. Fatigue has also affected
my patient's ability to breastfeed her daughter effectively which leads to a diagnosis
of Interrupted Breastfeeding. My patient's Impaired Physical Mobility also
contributes to her Risk for Infection since she has not been able to produce ample
urine after her catheter was removed.
 Evaluates nursing care outcomes through the acquisition of data and the questioning of
inconsistencies.
 Example: My patient c/o dizziness and nausea 24-hrs postpartum and was oliguric.
Since preeclampsia was a valid concern, her vital signs were reassessed, and her HR
and blood pressure were found to be within her baseline levels. Her most recent
bloodwork showed that the mag sulfate given for her preeclampsia was within
therapeutic range, however nausea was common a side effect of the medication. New
 bloodwork and a straight catheter was taken to confirm that she was not preeclamptic
such as checking for proteinuria, elevated creatinine and uric acid levels, low platelet
counts, decreased fibrinogen, and elevated PT or aPTT.
 Revises actions and goals based on evidence rather than conjecture.
 My patient was initially rated as a high-fall risk after delivery because she received an
epidural analgesic and mag sulfate during delivery. She c/o dizziness and nausea but
was not preeclamptic and there were no limitations on her getting out of bed as long
as she had nurse or care partner assistance. It was a goal that she ambulated 24-hours
post-delivery to reduce risk of DVT and she also expressed a desire to breastfeed her
infant who was at the Special Care Nursery. Therefore, to achieve the goal of
ambulating, she was told to keep her bed at a 30-degree angle and rehydrate by
drinking fluids. After observing her ambulate with assistance, she was re-evaluated
using the Braden Fall Risk Scale and it was determined that she was a low-fall risk
and could mobilize independently.
 Engages in creative problem solving
 Example: My patient was concerned about breastfeeding her newborn twins since one
was unable to latch properly and the other baby was in the special care unit down the
hall. Therefore, my recommendation to the mother was to request a lactation
specialist to help teach proper latching techniques and provide education on breast-
pumping. I also informed the mother that she would need to try to muster the strength
and energy to get out of bed and ambulate to the special care unit regularly to develop
a feeding schedule for the baby and use the breast-pump in-between.

 Nursing Practice
 Applies appropriate knowledge of major health problems to guide nursing practice.
 In this case study, my patient was a twenty-six-year-old Caucasian female, married,
G1P2, and pregnant with diamniotic/dichorionic twins. She used intrauterine
insemination (IUI) to become pregnant. Antepartum concerns for the patient include
morbid obesity as she had a BMI of 50.98 kg/m^2, a history of depression, asthma,
anxiety. During her pregnancy, she also had new-onset hypertension, hyperemesis
gravidarum, and end-stage renal disease. My patient was admitted at 36 weeks and 3
days for oligohydramnios with baby A and presented with preeclampsia with severe
features such as high blood pressure. She had no bleeding and felt the babies moving.
 Performs therapeutic interventions that incorporate principles of quality management
and proper safety techniques.
 Example: In caring for my postpartum patient, I assisted my nurse in administering
pain and anti-hypertensive meds. To do this I used quality management and safety
protocols such as the 5 rights of medication administration which required that I
recheck her heart rate and blood pressure and inquire about allergies.
 Implements traditional nursing care practices as appropriate to provide holistic health
care to diverse populations across the life span.
 Example: The traditional nursing care discussed in this case study included
performing a head-to-toe assessment on the patient and monitoring her vitals and
I/O's. The patient of this case study was a postpartum female; her family members
were her newborn infant and her wife. A focused BUBBLE-HE assessment of my
patient revealed that her breast was pendulous, nipples intact, warm upon palpation,
 and no colostrum because they were not filling yet. The nurse palpated a dime size
nodule on the left breast, deep around two o'clock, and noted it in her record. There
was no pain from nodule when palpated. Her fundus was firm at two finger breadths
above umbilicus. At the time the focused assessment was done, she had no void since
her Foley was removed and her bladder was not palpable. Her bowel sounds were
hypoactive in all four quadrants, she did not have gas, no bowel movements, and had
one skin tag that was 1/2 of a dime on her perineum. She was encouraged to use the
peri bottle, Americaine spray, and Tucks at bedside. Her lochia was a moderate rubra.
She had no episiotomy, and her second-degree laceration was intact with no
observable redness or swelling. She was negative bilaterally for Homan's sign. She
had 1+ edema on her right tibia and 2+ on her left tibia. Her feet were puffy and
swollen bilaterally. She had no headache, no blurred vision, no epigastric pain. She
stated her pain was a 3 out of 10 on a numeric scale. She was attempting to breastfeed
baby B and then wanted to go to special care nursery to feed her other newborn. Her
partner seemed worried that they needed to get to the special care unit to feed the
other baby by 1100. Later on, my patient's first void after her Foley was removed
measured at 300 mL.
 Demonstrates an awareness of complementary modalities and their usefulness in
promoting health.
 Example: I used complementary modalities to plan care for my patient by identifying
outside resources that could help with postpartum fatigue and depression, such as the
use of support groups, particularly women's depression peer support group and
resources such as a lactation specialist to help the mother learn how to breastfeed and
pump milk. I also used techniques to reduce the patient's anxiety and improve the
mother-baby bonding time, such as dimming lighting, reducing noise, and cluster
care.

 Communication
 Uses therapeutic communication within the nurse-patient relationship.
 Example: In this case study, I encouraged therapeutic communication by identifying
the patient's needs through discussion of the mother and family member's concerns
about not being able to breastfeed properly. My patient was attempting to breastfeed
baby B and then wanted to go to special care nursery to feed her other newborn. Her
partner seemed worried that they needed to get to the special care unit to feed the
other baby by 1100. Therefore, I recommended scheduled times for her to walk to the
special infant unit to breastfeed her son and I also recommended consultation with a
lactation specialist to teach her how to get her baby to latch properly and use of a
breast pump.

 Teaching
 Provides relevant and sensitive health education information and counseling to patients,
and families, in a variety of situations and settings
 Example: A nursing intervention for my postpartum patient's diagnosis of Risk for
Infection was to educate the patient about perineal care with the use of the peri-bottle
and sanitary napkins and then encouraging the patient to practice this self-hygiene. I
instructed the patient on the proper technique of rinsing with a peri-bottle and
 changing of ice-pads and sanitary napkins.

 Research
 Differentiates between descriptive nursing literature and published reports of nursing
research.
 Example: In this case study, I used descriptive nursing literature to support my
findings to identify my patient's risk factors. Preeclampsia was the main risk factor in
my patient's care. I noted that at 34-weeks gestation, she had two high blood pressure
readings (>160/110 mm Hg) that were taken consecutively and were flagged in her
record as severe preeclampsia (Lowdermilk et al., 2016, p. 654). I also noted that my
patient was also morbidly obese, with a body mass index (BMI) of 50.98 kg/m2,
which put her at a greater risk to develop preeclampsia since an obese woman is 2 to
3 times at greater risk than a woman with a normal BMI (Phillips & Boyd, 2016).
Phillips & Boyd (2016) also state that nulliparity and multiple gestation are risk
factors for preeclampsia and Anderson & Schmella (2017) state that in vitro
fertilization is a risk factor. I also used nursing research to support interventions in
caring for my patient's postpartum anxiety and depression and interrupted breast
feeding. I found that peer-support programs are acceptable to program attendees and
they provide a mechanism for improving mental health outcomes. I also found that
breast milk expression and education and support intervention was beneficial for the
establishment and maintenance of adequate breast milk production for preterm infants
(Heon et al., 2016).
 Evaluates research that focuses on the efficacy and effectiveness of nursing interventions.
 Example: In this case study, I used two nursing research articles to provide examples
of evidence-based practice that could be implemented in my care. One of the nursing
interventions for my patient's diagnosis of Fatigue could have been to inform her of
resources such as a women's depression peer support group. A study examined
participant satisfaction with and effectiveness of a peer-facilitated postpartum support
group. Data was provided by the sponsoring organization (n = 73) and follow-up data
was collected through an online survey from program attendees (n = 45) (Prevatt et
al., 2018). A community sample was also recruited to establish a comparison group (n
= 152) (Prevatt et al., 2018). Results found that participant satisfaction was high with
overwhelmingly positive perceptions of the program (Prevatt et al., 2018). Therefore,
peer-support programs are acceptable to program attendees and they provide a
mechanism for improving mental health outcomes. A nursing intervention for my
patient's diagnosis of Interrupted` Breastfeeding was for her to identify and
demonstrate the use of a breast pump to sustain lactation until breastfeeding is
reinitiated by the end of the shift. A study was conducted on 40 mothers of
hospitalized preterm infants to estimate the effects of a breast milk expression
education and support intervention on breast milk production outcomes in mothers of
very and extremely preterm infants (Heon et al., 2016). The results showed that a
breast milk expression and education and support intervention was beneficial for the
establishment and maintenance of adequate breast milk production for preterm infants
(Heon et al., 2016).

 Leadership
  Articulates the values of the profession and the role of the nurse as member of the
interdisciplinary health care team.
 Example: In this case study, I described how the registered nurse, along with the
healthcare provider met the requirements of AWHONN by collecting health data
from Mrs. B, prioritizing the data collection based on Mrs. B's needs, and
documenting the data in the patient's record (AWHONN, 2009). Mrs. B's vital signs
and lab work revealed that she had signs and symptoms of preeclampsia. Her
healthcare was then transferred to a hospital for high-risk patients. Thorough
assessments were completed during each visit. Upon her first visitation, at 34 weeks
gestation, her blood pressure reading was high at 148/84 mm Hg and her uric acid
level was high at 9.7 mg/dL. Interventions were planned and executed to lower Mrs.
B's blood pressure as she was prescribed an antihypertensive medication. Patient
teaching was also conducted as Mrs. B was also instructed by the nurse on how to
monitor her blood pressure at home twice per day. Other interventions included
monitoring of Mrs. B's urine protein, therefore 24-hour protein measurements were
required. Assessments were constantly made by the nurse and healthcare staff as data
was collected on a weekly basis from Mrs. B. Weekly interventions such as
ultrasounds were also performed weekly to measure amniotic fluid index and fetal
growth. When oligohydramnios was discovered in baby A, an intervention was made
at 36 weeks and 3 days to augment labor. Mrs. B's needs were met as she was given
thorough care throughout her pregnancy, remained free from eclampsia, and was able
to vaginally deliver two healthy babies.

 Professionalism
 Differentiates between general, institutional, and specialty-specific standards of practice
to guide nursing care.
 Example: In this case study, I used the nursing process, AWHONN and hospital
Standards of Care such as BUBBLE-HE which was done every 4 hours as part of my
postpartum maternal nursing assessment. I also followed hospital safety protocols for
ambulation to allow my patient to feed the baby in the special infant nursery.
 Applies ethical decision-making framework and legal guidelines to clinical situations that
incorporate moral concepts, professional ethics, and advocacy for patient well-being
preferences.
 Example: In this paper, I discussed how I advocated for the patient's desire to
breastfeed her baby by recommending expert advice through support of a lactation
specialist as well as advising to schedule regular visits to the baby in the special care
nursery to breastfeed.

 Culture
 Articulates an understanding of how human behavior is affected by culture, race,
religion, gender, lifestyle and age.
 Example: In this case study, I identified the importance of my patient's support
system. My patient was in a same-sex marriage, therefore there were two mother's
that were present and concerned about the breastfeeding of the newborn infants.
Therefore, I ensured that I was communicating my efforts and nursing
recommendations to both. I encouraged the wife to participate in the care of the
patient and of the newborns. My patient's partner assisted her with self-care and
hygiene and she was also present during scheduled breastfeeding with the baby in the
special care unit.