Case Study

Case Study
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Case Study

Chief Complaint/Chief Concern

K.F. is a 36 y.o. female admitted to the hospital for a repeat cesarean section at 39 weeks
gestation.

History of Present Illness

K.F. is G4P4004 and has had 2 previous c-sections. She delivered at 8:26 a.m. on 4/1/17. Tested
positive for Group B streptococcal infection and preeclampsia.

Past Medical History

The patient’s past medical history includes: gestational thrombocytopenia, anxiety, mild
scoliosis, Hashimoto’s thyroiditis, impaired vision (wears glasses/contacts), Group B
streptococcal infection in pregnancy, pregnancy induced hypertension (admitted pp for mg),
preeclampsia, occasional migraine when pregnant, and uterine anomaly (fibroid).

Past Surgical History

The patient’s past surgical history includes: 2 cesarean sections (2011, 2015), tonsillectomy, foot
surgery, and myomectomy (2010).

Medications/Allergies
No known allergies.
Medications:
Acetaminophen (TYLENOL) tablet 650 mg, q6h, PO, for mild pain
Bisacodyl (DULCOLAX) 10 mg, daily PRN, RE, for constipation
Cefazolin (ANCEF) 2 g IVPB 50 mL, once, IV,
Citric acid-sodium citrate (BICITRA) 30 mL, once PRN, PO, for heartburn
Docusate sodium (COLACE) 200 mg, 2 times daily PRN, PR, for constipation
Fentanyl (SUBLIMAZE) 25 mcg, every 5 min PRN, IV, for pain
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Hydromorphone (DILAUDID) 0.5 mg, every 5 min PRN, IV, for pain
Ibuprofen (ADVIL, MOTRIN) 600 mg, 4 times daily, PO, for mild pain
Lactated ringers infusion 125 mL/hr, continuous, IV
Lanolin ointment, every 2 hours PRN, for dry skin/nipple discomfort
Levothyroxine (SYNTHROID, LEVOTHROID) 88 mcg, daily, PO, for Hashimoto
thyroiditis
Meperidine (DEMEROL) 12.5 mg, every 10 min PRN, IV, for shivering
Nalbuphine (NUBAIN) 5 mg, every 4 hours PRN, SC, for itching
Naloxone (NARCAN) 0.1 mg, PRN, IV, for opioid reversal
Oxycodone-acetaminophen (PERCOCET) 2 tablets, every 4 hours PRN, PO, for
moderate to severe pain
Oxytocin (PITOCIN) 30 units in lactated ringers 500 mL infusion, 125 mL/hr,
continuous, IV
Simethicone (MYLICON) 160 mg, 3 times daily PRN, PO, for flatulence

Smoking and Alcohol (and any other substance abuse)

No history of substance abuse.

Family/Social/Work History
No significant family, social, or work history.

Pathophysiology
Preeclampsia – Preeclampsia is a multisystem disorder defined as hypertension accompanied by
proteinuria after the 20th week of gestation. It is diagnosed by the presence of hypertension and
either proteinuria (greater than or equal to 300 mg in a 24 hr collection or protein/creatinine
ration greater than or equal to 0.3 or protein dipstick reading of 1+) or, in the absence of
proteinuria, new onset hypertension with platelet count less than 100,000/microliter, serum
creatinine concentrations greater than 1.1 mg/dl, elevated blood concentrations of liver
transaminases to twice normal concentrations, pulmonary edema, or cerebral or visual changes
(Uzan, J., Carbonnel, M., Piconne, O., Asmar, R., & Ayoubi, J.M., 2011). The patient can be
treated with Magnesium Sulfate, and also observed every 4 hours for 48 hours for clonus, deep
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tendon reflexes, epigastric pain, blurred vision, and headaches. Vital signs are also closely
monitored. The only cure for preeclampsia is delivery.

Group B streptococcus – GBS is a bacteria found in the intestines, vagina or rectum of 25% of
healthy adult women. These women can pass the bacteria to their baby during delivery, but not
all infants become infected if the mother is. Signs and symptoms that there is a higher chance of
delivering a baby with GBS include labor or premature rupture of membranes before 37 weeks,
rupture of membranes 18 hours or more before delivery, fever during labor, a UTI, and a
previous baby with GBS. All pregnant women are routinely tested for GBS as per CDC
guidelines between the 35th and 37th week of gestation. If the test is positive, they will receive an
antibiotic at least 4 hours before delivery. If they receive the antibiotic less than 4 hours before
delivery or if the infant is less than 35 weeks gestation, the infant will be observed for sepsis for
at least 48 hours. Signs and symptoms of early-onset GBS in infants include sepsis, pneumonia,
meningitis, breathing problems, unstable BP, and GI and kidney problems.

Hashimoto’s thyroiditis – Hashimoto’s thyroiditis is an autoimmune disorder also known as

chronic lymphocytic thyroiditis, and the most common cause of hypothyroidism. Antibodies
attack the thyroid gland, which eventually impairs the thyroid’s ability to produce thyroid
hormones causing hypothyroidism. Hashimoto’s progresses slowly, so symptoms may be hard to
identify or notice. Chronic cell damage overtime causes a goiter, or enlarged thyroid, and gradual
thyroid failure. Patients will notice symptoms of hypothyroidism, including fatigue, weight gain,
constipation, increased sensitivity to cold, dry skin, depression, muscle aches, reduced exercise
tolerance, and irregular or heavy menses. Treatment consists of thyroid hormone replacement.

Physical Assessment
K.F. -

 Vital signs: Temp 97.7, HR 70, BP 124/74, RR 16, O2 Sat 99%, Pain 5
 Level of Consciousness: Alert and oriented x4
 Head, Eyes, Ears, Nose, Throat: Pupils equal, round and reactive to light, ears and nose
are normal, throat is pink and moist, head is symmetrical
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 Lungs: Equal breath sounds bilaterally, no wheezing/coughing

 Cardiac: Regular rhythm, pulses 2+, non-pitting edema in ankles
 Breasts: medium with inverted nipples, colostrum present
 Abdomen: Firm fundus, U/1 – midline
 GI:
 GU: Foley catheter in place, normal urine output and color
 Extremities: non-pitting edema in R/L ankles
 Skin: Normal color, even skin tone, abdominal incision dry, no redness/swelling/drainage

Baby –

 Apgar scores: 8 @ 1 min, 9 @ 5 min

 Length: 20”
 Weight: 3000 g
 Head circumference: 34.3 cm
 Vital signs: Temp 98.4, HR 146, RR 42, Glucose 58
 General appearance: good muscle tone and posture, active
 Skin: Pink skin color, small stork bite on left eyelid, no newborn rash
 Head and neck:
 Lungs: Normal breathing pattern
 Cardiac: Normal heart rate, S1 and S2, no S3 or S4, no murmur
 Abdomen: Normal
 Genitals and anus: Patent anus
 Extremities: Normal movement and development

Lab results

Lab Test Patient’s Result Normal Range Pathophysiology

WBC 4/1: 9.98 4.5-10 mcL WNL
4/3: 8.26
HGB 4/1: 11.8 13.8-17.2 gm/dL Low
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4/3: 10.3
HCT 4/1: 35.6 42-54% Low
4/3: 31.2
PLT 4/1: 133 140-400 mcL
4/3: 154
RBC 4/1: 3.77 Low
4/3: 3.26
GLUCOSE 4/3: 82
BUN 4/3: 6.0 6-22 mg/dL Low
CREATININE 4/1: 0.7 0.7-1.3 Normal
4/3: 0.7
AST 4/1: 19 14-20 u/L Normal
4/3: 17
BILI TOTAL 4/3: 0.3 0.3-1.9 mg/dL Normal
ALB 4/3: 2.4 3.4-5.4 g/dL Low
URIC ACID 4/1: 5.2
PT 4/1: 12.9 11-13.5 sec. Normal
INR 4/1: 1.0 0.8-1.1 Normal
ABO Rh A POS
GBS 3/15: Positive
TRANSCRIBED

Nursing Diagnosis #1: Anxiety RT fear and stress over current condition AEB elevated BP
and patient statements.
 Interventions:
1. Provide extensive patient education to help ease patient and allow patient time to
ask questions during hourly rounding.
2. Teach patient 3 relaxation techniques that the patient can teach back by the end of
shift.
 Outcomes:
1. Patient will experience decreased anxiety due to extensive knowledge regarding
her and her baby’s conditions by the end of shift.
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2. Patient will teach back and have practiced 3 relaxation techniques and
experienced a decrease in anxiety by the end of shift.
Nursing Diagnosis #2: Insufficient breast milk RT delayed milk supply AEB baby crying,
looking for breast, and losing over 10% of body weight.
 Interventions:
1. Suggest formula feedings or other ways to supplement and keep baby’s weight up
until the mother’s milk comes in.
2. Teach patient 3 techniques for stimulating breasts and milk formation, such as
pumping or practicing skin to skin with baby.
3. Patient will meet with a lactation consultant to receive further education on
breastfeeding by the end of shift.
 Outcomes
1. Patient will implement at least one intervention to keep the baby from losing more
than 10% of her body weight.
2. Patient will demonstrate 3 measures to ensure adequate milk supply by end of
hospital stay.
3. Patient will implement at least 2 techniques learned from the lactation consultant
by the end of shift.
Nursing Diagnosis #3: Risk for injury RT signs of preeclampsia AEB hypertension and
proteinuria.
 Interventions:
1. Observe patient for signs of worsening condition such as blurred vision,
headache, alteration in level of consciousness, epigastric pain, hyperreflexia every
4 hours for 48 hours.
2. Monitor intake and output throughout shift.
3. Educate the patient on warning signs and symptoms of disease progression at
beginning of shift.
 Outcomes:
1. Patient will not demonstrate any signs or symptoms of worsening condition by
end of shift and end of 48 hour observation period.
2. Intake and output with remain within normal limits throughout shift.
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3. Patient will be able to teach back at least 5 warning signs and symptoms of
worsening condition.

References

Group B Strep Infection: GBS. (2017, March 02). American Pregnancy Association. Retrieved
April 17, 2017, from http://americanpregnancy.org/pregnancy-complications/group-b-strep-
infection/
Hashimoto’s Thyroiditis. (n.d.). Retrieved April 17, 2017, from
http://www.thyroid.org/hashimotos-thyroiditis/
Uzan, J., Carbonnel, M., Piconne, O., Asmar, R., & Ayoubi, J.M. (2011). Pre-eclampsia:
Pathophysiology, diagnosis, and management. Vascular Health and Risk Management, 7, 467-
474. DOI: 10.2147/VHRM.S20181
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3148420/#