Simulation Activity 5: GENITOURINARY, OBSTETRIC, and GYNECOLOGIC

EMERGENCIES and CRITICAL SKILLS

You are the 3-11 NURSE in the Maternal Intensive Care Unit of Saint Louis University Hospital of the Sacred Heart.
Your patient is Mrs. Cruz, a newly admitted pregnant woman diagnosed with Pregnancy Induced Hypertension and
Urinary Tract Infection.

After listening to the change of shift report and reviewing the patient's record, you noted the following:

Mrs. Cruz is...35 years old, married, multigravida, gravida 4 and para 3, all surviving. No history of abortion, stillbirth,
cesarean section or any obstetric complications.

The current pregnancy was her fourth with a gestational age of approximately 34 weeks at presentation.

Mrs. Cruz seldom goes for prenatal check-up due to location and distance of their local rural health unit. No known
history of other medical conditions except for iron deficiency anemia diagnosed during her third pregnancy. Has
unrecalled history of immunizations. No known allergies. No prenatal meds taken.
Her husband is a smoker. He smokes 1 pack/day.

STATE 1 - Assessment, Health History, Diagnostics, Problem Identification, Planning

They are both gardeners living in the rural area.

Physician's Order Sheet

Diet: Diet as tolerated
Activity Restriction: CBR w/o BRPs (complete bed rest without bathroom privileges)
Diagnostics: CBC, Platelet, U/A, 24-hour urine collection for total protein and creatinine clearance test, FBS, FBS, BUN, se.
CREA, se. Electrolytes
IVF: PNSS 1L x KVO
Medications:
- Calcium (Tums) 1gm 1 tab daily.
- Mutivitamins (MVS) 1 tab OD.
- Fe + Folic Acid (Iberet) 1 tab OD.
- Methyldopa 250mg/tab 1 tab every 8 hours.
- MgSO4 1g in 50cc NSS per soluset every 1 hour for 20 doses.
- Hydralazine 5mg IV for BP> 160/100.
- Diazepam 5mg IV PRN for frank seizure.
- Dexamethasone 5 mg IM every 12 hours x 2 doses.
Vital Signs: Monitor VS hourly and record.
Intake and Output: Monitor intake and output hourly and record.
Special Endorsement:
- Seizure Precautions
- Weigh daily
- Monitor FHR hourly and record, monitor fetal movements hourly and record
- Hook to CTG machine.
Contraptions:
- Low flow oxygen therapy at 1-2 LPM per nasal cannula
- IFC to HCB
After the shift report and review of medical record, you entered the patient's room. You are now interviewing Mrs. Cruz and doing
your assessment as well...

Mrs. Cruz claims that as her pregnancy progressed, she noticed sudden weight gain in the second trimester, approximately 2 lbs.
per week ...accompanied by generalized body swelling that started from her eyes, then face, and eventually migrated to her legs.
She is 5'1" in height and currently weighs 67 kg.

Upon inspection, you noticed the following :

she also experienced blurring of vision...

and headache..

Moreover, she said that prior to admission, she had two to three episodes of seizure, was unconscious, and was taken to a nearby
health facility (health center) by her husband and mother. The health care provider diagnosed her as having pregnancy induced
hypertension and was referred to the nearby general hospital.

Because of shortage of supply and equipment, except for urine analysis by dipstick method (protein 3+), no other laboratory or
other investigative tests was done at the health center.
Assessing further, you took her temperature and it is 38 °C…
Her BP is 170/110 mmHg…. Respiratory rate is 22 cpm, pulse rate is 82 bpm and SPO2 is 95%.

Fetal heart rate is 142 bpm and 10 fetal kicks in one hour...

1. Based on your assessment, what type or classification of Pregnancy Induced Hypertension does
your patient have? *

Based on the assessment, the classification of Pregnancy Induced Hypertension that the patient have is
Eclampsia.

2. What is the clinical feature of your above condition based on your answer in question number
1? *

The clinical feature that can be seen in a patient with eclampsia are the following: Episodes of seizures
accompanied by signs and symptoms of pre-eclampsia such as De Novo hypertension with a blood pressure
of 170/110 mmHg after 20 weeks gestation. Neurological complications such as headache and blurring of
vision. Generalized edema and sudden weight gain of more than 2 lb/wk in the second trimester this
usually indicates abnormal tissue fluid retention. Epigastric pain. Marked proteinuria 3+ or 4+ on a
random urine sample. Increase creatinine level and Increase ALT/AST.

3. Looking into the patient's history, what could have caused the development of her condition? Select
all that apply. Note: Two points for complete and correct answers, one point for 1 incorrect or missing
answer, and zero point for 2 or more incorrect or missing answers. *

2 points

A. Age of 35 y/o
B. AOG of 34 weeks
C. OB score of G4P3 (3003)
D. Husband is a smoker of 1 pack/day
E. Client is a gardener.
F. Poor prenatal check-up
G. No prenatal meds taken
H. Client lives in the rural area
I. Unknown history of immunization
J. History of iron deficiency anemia
K. Weight of 67 kg and height of 5'1"

4. Which among the following nursing problems will you prioritize given the current condition of your
patient? *
1 point

A. Social isolation related to prescribed bed rest

B. Deficient fluid volume related to fluid loss to subcutaneous tissue
C. Ineffective tissue perfusion related to vasoconstriction of blood vessels
D. Risk for fetal injury related to reduced placental perfusion secondary to vasospasm
5. Justification (of your answer in question #2) *

With PIH, vasoconstriction occurs and blood pressure increases dramatically. Ineffective tissue perfusion related to
vasoconstriction of blood vessels is the first prioritized problem because due to the vasoconstriction of blood vessels and
rising peripheral resistance it reduces the blood supply to organs, most markedly the kidney causing glomerular damage,
in liver causing elevation of liver enzymes and stretches capsule leading to epigastric pain. Decreased blood supply to the
brain also occurs, causing neurological complications such as seizures. Furthermore, decreased blood supply to the
placenta also occurs, which can cause poor placental perfusion that may reduce the fetal nutrient and oxygen supply,
leading to intrauterine growth restriction and fetal death. If this problem is managed accordingly, it will alleviate the
client’s situation and improve her condition; thus, resolving other identified problems.

6. The Physician ordered for routine urinalysis and you are about to collect urine sample via the IFC
when you noticed that there is insufficient amount of urine in the catheter tubing. What is your
appropriate nursing action? Select all that apply. Note: Two points for complete and correct answers,
one point for 1 incorrect or missing answer, and zero point for 2 or more incorrect or missing
answers. *
2 points

A. Aspirate directly from the IFC port using a 10 cc syringe.

B. Kink the IFC tubing midway and drain the urine collected in the tubing.
C. Kink the IFC tubing near the port and wait for at least 30 minutes.
D. Check for kinks, loops or clots in the catheter or drainage bag tubing.
E. Palpate the bladder and note for any patient pain or discomfort.
F. Monitor vital signs.
G. Raise the bag 3 to 6 inches above the pubis.
H. Insert a new catheter.
I. Flush the IFC with 50 cc air.
J. Turn the patient to his side.

7. Patient suddenly complains of lower abdominal pain despite of having an IFC. What immediate
measures will you perform to correct this problem? Select all that apply. Note: Two points for complete
and correct answers, one point for 1 incorrect or missing answer, and zero point for 2 or more
incorrect or missing answers. *
2 points

A. Advise patient to increase her fluid intake.

B. Palpate the bladder and note any patient pain or discomfort.
C. Perform immediately intermittent closed catheter irrigation.
D. Perform immediately continuous closed bladder irrigation.
E. Check for kinks, loops or clots in the catheter or drainage bag tubing.
F. Perform open intermittent catheter irrigation.
G. All of the above
H. None of the above.

8. The routine urinalysis results came in and showed elevated level of pus cells (10-12/HPF) and
bacteria (30-35/HPF). The appearance is turbid and 3+ protein was also noted. What can you infer
based on this assessment? Select all that apply. Note: Two points for complete and correct answers, one
point for 1 incorrect or missing answer, and zero point for 2 or more incorrect or missing answers.  *
2 points

A. Values are within normal range

B. Findings are normal with a

C. Client has CKD

D. Client has bacteriuria
E. Client has pyuria
F. Client has proteinuria
G. Client has albuminuria
H. Client has septicemia
I. Client has pyelonephritis
J. Client has uricemia
K. Client has hematuria

Turbid urine...

9a. As part of her plan of care, you would need to anticipate to place the patient on: *
1 point
A. The ward with other parturient patients to allow socialization.
B. The isolation room to prevent patient from distracting other patients.
C. The dark isolated room to decrease external stimulation.
D. None of the above
E. All of the above

9b. Justify your choice of action in 9a. *

Since the patient had episodes of seizure placing her in a dark isolated room is the best option because a loud noise
such as a crying baby or a dropped tray of equipment can be sufficient to trigger a seizure initiating eclampsia.
Furthermore, darken the room if possible because a bright light can also trigger seizures.

End of Simulation Activity : STATE 1