NCM 109

Case Study

INSTRUCTIONS: Data attached on stream, then answer the questions:

HEMATOLOGIC (THROMBOCYTOPENIA IN A NEONATE)

This patient is a 33-year-old Caucasian pregnant woman, G3P2, group A Rh(D) positive pregnant
woman who had previously delivered an infant (G1) with petechiae at birth and a markedly low platelet
count (12 x 103/μL; normal reference range: 150–400 x 103/μL). This infant was treated with intravenous
immune globulin and random platelet transfusions. Because of this history, early in her third pregnancy, her
serum was screened for the presence of platelet antibodies. The maternal platelet antibody screen was
positive for anti-human platelet antigen (HPA)-1a and class I human leukocyte antigen (HLA) antibodies.
The maternal platelet antigen type was HPA- 1b/1b and the paternal antigen type was homozygous HPA-
1a. The patient chose monthly ultrasound testing and periodic cordocentesis to assess fetal platelet count
and to decrease the risk of delivery-related complications. Cordocentesis was performed to assess the
infant’s platelet count at 26 5/7 weeks and 33 weeks gestational age (GA). The fetal platelet count was 176
x 103/μL and 169 x 103/μL, respectively. The fetal platelet antigen type was HPA-1a/1b. The fetus (G3)
was delivered vaginally and had a platelet count of 213 x 103/μL. Her past obstetrical history during her
second pregnancy, ultrasound was performed at 6, 10, and 18 weeks GA and no gross abnormalities were
noted. Amniocentesis was performed at 21 weeks GA and polymerase chain reaction (PCR) testing
confirmed that the fetus was platelet type HP-1a/1b. The fetal platelet count was monitored by 4 serial
cordocentesis performed between 21 and 34 weeks GA. Fetal platelet counts ranged from 110–129 x
103/μL. No medical therapy was provided during this pregnancy because the fetal platelet counts remained
above 100 x 103/μL. The infant (G2) was delivered vaginally and had a platelet count of 146 x 103/μL. Past
Surgical History: Knee surgery. Social History: Unremarkable. Family History: Unremarkable, no family
history of neonatal thrombocytopenia. Allergies: Codeine.

1. Identify the important maternal and newborn data (20points)

Maternal Neonatal
 33 y/o Caucasian  Platelet count at 26 5/7wks AOG: 176 x 103/μL
 G3P2  Platelet count at 33 wks A0G: 169 x 103/μL
 Group A Rh (D)+  Fetal platelet antigen type HPA-1a/1b
 Anti-human platelet antigen HPA-1a+ and  Delivered vaginally
Class I Human Leukocyte Antigen antibodies  Platelet count at delivery: 213/103/μL
 Platelet antigen type HPA-1b/1b
 Allergic to codeine

2. Create an NCP as related to data taken from the mother and the newborn. (1maternal and 1 newborn
related NCP) (20points)
 MATERNAL NCP

Assessment Nursing Planning Nursing Rationale Evaluation

Diagnosis Intervention

OBJECTIVE: 3rd Dx STG: Independent: STG:

Risk for bleeding  Monitor patient’s vital  Hypotension and
 33 y/o Caucasian related to After 2 hrs of signs, especially BP tachycardia are After 2 hrs of
nursing intervention, and HR. Look for initial compensatory nursing intervention,
 G3P2 alloimmune
the patient takes signs of orthostatic mechanisms the patient takes
 Group A Rh (D)+ thrombocytopenia measures to prevent hypotension. usually noted with measures to prevent
 Anti-human as evidenced by bleeding and bleeding. bleeding and
platelet antigen platelet recognizes signs of Orthostasis (a drip recognizes signs of
HPA-1a+ and incompatibility. bleeding that need of 20 mm Hg in bleeding that need
Class I Human to be reported systolic BP or 10 to be reported
Reference:  immediately to a mm Hg in diastolic immediately to a
Leukocyte
health care BP when changing health care
Antigen Doenges, M. E.,
professional. from supine to professional.
antibodies Moorhouse, M. F., sitting position)
 Platelet antigen Murr, A.C. Nurse’s LTG: indicates reduced
type HPA-1b/1b Pocket Guide: circulating fluids. Goal Met.
 Allergic to Diagnosis, After 48 hrs of  Assess skin and  Patient with
Prioritized nursing intervention, mucous membranes reduced platelet LTG:
codeine
Interventions and the patient does not for signs of counts or impaired
experience bleeding petechiae, bruising, clotting factor After 48 hrs of
Rationales. (14th
as evidenced by hematoma formation, activity may nursing intervention,
ed.). pp. 67-72 or oozing of blood.
normal blood experience the patient does not
pressure, stable bleeding into experience bleeding
hematocrit and tissues that is out of as evidenced by
hemoglobin levels. proportion to the normal blood
injury. pressure, stable
 When bleeding is hematocrit and
 Monitor hematocrit
not visible, hemoglobin levels.
(Hct) and hemoglobin
decreased Hgb and
(Hgb).
Hct levels may be
an early indicator of Goal Met.
bleeding.
 Educate the at-risk  Information about
patient about precautionary
precautionary measures lessens
measures to prevent the risk for
tissue trauma or bleeding.
disruption of the
normal clotting
mechanisms.
 Educate the patient  Early evaluation
and family members and treatment of
about signs of bleeding by a
bleeding that need to health care provider
be reported to a reduce the risk for
health care provider. complications from
blood loss.
Dependent:
● Administer blood
 Blood product
transfusion as
transfusions
prescribed by
replace blood
the doctor when
clotting factors;
laboratory
RBCs increase
values are
oxygen-carrying
 abnormal. capacity; FFP
replaces clotting
factors and
inhibitors; platelets
and cryoprecipitate
provide proteins for
coagulations.
Interdependent:
 Refer to an OB-  For further
GYNE. assessment and
interventions for the
healthcare of the
patient.

NEONATE NCP

Assessment Nursing Planning Nursing Rationale Evaluation

Diagnosis Intervention

OBJECTIVE: 3rd Dx STG: Independent: STG:

Risk for bleeding ● Monitor ● Decrease in
 Platelet count at related to neonatal After 2 hrs of hematcrit and Hct and Hgb After 2 hrs of
26 5/7wks AOG: nursing intervention, hemoglobin levels may be nursing intervention,
alloimmune
the patient’s values. an early the patient’s
176 x 103/μL thrombocytopenia significant are indicator of significant are
 Platelet count at as evidenced by educated about the bleeding. educated about the
33 wks A0G: 169 platelet signs of bleeding ● Educate the ● Early signs of bleeding
x 103/μL incompatibility. that need to be patient’s family evaluation and that need to be
 Fetal platelet reported about the signs treatment of reported
antigen type Reference:  immediately to a of bleeding that bleeding by a immediately to a
HPA-1a/1b healthcare need to be healthcare healthcare
Doenges, M. E.,
 Delivered professional as reported to a provider professional as
Moorhouse, M. F., evidenced by healthcare reduce the risk evidenced by
vaginally Murr, A.C. Nurse’s reporting to the provider. of reporting to the
 Platelet count at Pocket Guide: healthcare complications healthcare
delivery: Diagnosis, professionals as of blood loss. professionals as
213/103/μL Prioritized soon as signs are ● Provide ● This helps to soon as signs are
Interventions and observed. psychological give observed.
and emotional assurance and
Rationales. (14th
LTG: support to the calming to the
ed.). pp. 67-72 patient’s patient’s Goal Met.
After 48 hrs of significant parents.
nursing intervention, others. LTG:
the patient does not ● Tell the family ● Active
experience bleeding members to be participation After 48 hrs of
as evidenced by active in encourages nursing intervention,
normal blood decision-making full the patient does not
pressure, and about the understanding experience bleeding
display laboratory treatment of the of the rationale as evidenced by
values within normal patient at risk for and normal blood
range such as bleeding. compliance pressure, and
stable hematocrit with the display laboratory
and hemoglobin treatment. values within normal
levels and desired Dependent: range such as
ranges for ● Administer ● At birth, stable hematocrit
coagulation profiles. Vitamin K as newborns and hemoglobin
prescribed by have very little levels and desired
 the doctor’s Vitamin K ranges for
orders. stored in their coagulation profiles.
bodies that
may cause
them to bleed. Goal Met.
Vitamin K
helps to
quicken the
clotting
process.
● Administer IVIG ● It decreases
or Intravenous the production
Immune globulin of antiplatelet
as per doctor’s antibodies,
orders. neutralizes
circulating
antibodies,
blocks
destruction of
platelets and
decreases the
incidence of
Interdependent: IVH.
 Refer to ● For further
neonatologist. assessment
and
interventions
for the
healthcare of
the patient.

3. Identify both maternal and newborn health teachings (10 points)

 Promote good nutriton, adequate rest,

Maternal Health Teaching
Newborn Health Teaching
good hygiene, and breastfeeding.
 Educate mother about the importance of
regular antenatal care visits to protect
herself and the baby from complications
and ensure healthy well-being.
 Encourage the mother to seek help during
the postpartum period as she may feel
baby blues or postpartum depression.
 Educate the patient’s family about the
signs of bleeding that need to be reported
to a healthcare provider.
 Educate the newborn’s parents in the
importance of monthly immunization
procedures after birth.
 Educate about the importance of
monitoring the baby’s vital signs to
address immediately the complication that
may arise.
  Educate the patient’s family about the
signs of bleeding that need to be reported
to a healthcare provider.

FLUIDS AND ELECTROLYTES

As a senior student you are assigned to work with a preceptor in the Emergency Department. It is a
very busy day and it seems as if every patient, regardless of chief complaint, has an issue with fluid,
electrolyte, and/or acid-base balance. The first patient you see is a 7-year-old BOY who is brought to the
ED after collapsing while playing with his fellow classmates. He is slightly confused but is able to tell you he
feels dizzy and weak. His skin is flushed, dry, and with poor turgor. He has dry, sticky mucous membranes.
The nurse identifies a nursing diagnosis of deficient fluid volume.

1. Describe how each of the following would change and the rationale for the change in the presence of
deficient fluid volume: (identify if increase or decrease) (10pts)

 Heart rate (increase)

 Blood pressure (decrease)
 Serum hematocrit (increase)
 Urinary output (decreased)

Dehydration causes the heart to strain. When you are dehydrated, the amount of blood flowing through
the body, or blood volume, decreases. Your heart beats harder to compensate, increasing your heart rate
and triggering palpitations. Low volume of blood cells in the body causes the hematocrit levels to rise. When
the body is dry, the kidneys try to hold on to as much fluid as possible, urine output is decreased, and the urine itself
is concentrated.

2. The ED physician orders IV fluids for this patient. What types of fluids are indicated for a fluid volume
deficit due to dehydration? (5pts)

There are three main types of fluid volume deficit: isotonic, hypertonic, and hypotonic. Isotonic is

the most common and occurs when you lose equal amounts of fluid and electrolytes. Hypertonic occurs
when you lose more water than electrolytes and hypotonic refers to a greater loss of electrolytes
compared to water. Therefore, hypotonic IV fluid is used to treat fluid volume deficiency.

3. The preceptor tells you to go ahead and initiate an IV site and start the fluids. The fluid order is to start
1000 mL of fluid as ordered at 150 mL/hr. The infusion tubing has a drop factor of 15 gtt/mL. This
infusion will run by gravity rather than an infusion pump. How many drops per minute should you time
the infusion at to ensure the correct hourly rate? (5pts)
 ml drop
Formula: x drop factor=
min . min .

gtts
150 ml x 15
Solution: ml 2,250 gtts
= =37.5
gtts
60 mins . 60 min . min .

Therefore, 37.5 gtts/min. should be times to ensure correct hourly rate.

4. What drop factor should you be concerned about pediatric cases? (3pts)

For pediatric patients, the 60 gtt/ml is the most commonly used drop factor when small fluid volumes
are important. Microdrip is narrower and only produces small drops. Other drop factors like 10, 15, and
20 drops per ml are used in macrodrip tubing which is wider usually produces larger drops that could be
painful for the 7 y/o in the case.

5. Considering the diagnosis, patient presentation, and fluid orders, what size catheter is indicated in this
situation? Give a rationale for your choice. (7pts)

The size catheter for pediatric patients is gauge 24 due to its small size and since the fluid to be
infused is an oral rehydration solution, also called as half-normal saline — which contains 0.45% sodium
chloride and 5% glucose. This will prevent injury to the vein, resulting in a longer lasting IV site that
would slowly but surely be absorbed by the patient.