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Case Map
Mrs. Maguire, 26-year-old woman, comes to the clinic because of a 3-day history of lower abdominal pain. She is 18 weeks pregnant by date. She described the pain as sharp, steady, and radiating across her lower abdomen bilaterally. Last night she developed new nausea and vomiting. She has not been able to keep down any food or drink this morning. She had a normal bowel movement yesterday. She said she felt cold and shivering this morning, followed by feeling warm; however, she did not check her temperature. She denies any vaginal bleeding.
Assessment
Subjective data:
Subjective data
1.3-day history of lower abdominal pain
2. She described the pain as sharp, steady, and radiating across her lower abdomen bilaterally.
3. She verbalized that she developed new nausea and vomiting last night.
4.She has not been able to keep down any food or drink this morning.
5. She had a normal bowel movement yesterday.
6. She said she felt cold and shivering this morning, followed by feeling warm; however, she did not check her temperature.
7. She denies any vaginal bleeding.
Objective data:
Objective data
Vital Signs:
Temp - 38.8C
Pulse - 120 bpm
RR - 20cpm
BP- 110/70 mmHg
Ultrasound of KUB,
CVC abdominal Xray done.
Urinalysis Result:
Leukocyte esterase (+)
Blood (+)
Ketones (+) Bacteria (+)
WBCs- 30-50 per high power field
Nitrites (+)
Protein (-)
STD panel:
Urine gonorrhea/chlamydia/trichomoniasis (-)
Diagnosis
Risk for infection
Risk for infection (spread/septic shock) possible evidenced by risk factors of presence infection, broken skin, and/or traumatized tissues; rupture of amniotic membranes; high vascularity of involved area; stasis of body fluids; invasive procedures, and/or increased environmental exposure, chronic disease (eg.,diabetes, anemia, malnutrition) altered immune response; and untoward effects of medications (e.,g opportunistic, secondary infection).
Planning
After 45 mins - 1 hour of nursing intervention, the patient will display body temperature within normal range.
Intervention
and
Rationale
INTERVENTION
RATIONALE
Independent:
Perform nonpharmacologic measures, such as encouraging the patient to wear lightweight clothing, and maintaining a comfortable room temperature.
Assess for specific signs and symptoms if present.
Provide isolation and monitor visitors as indicated.
Wash hands before and after each care activity, even gloves are used.
Provide information about possible effects of infection on the patient/fetus.
Bundling up with too much clothing and being exposed to extra ambient heat can cause the body temperature to rise making it harder to reduce a fever.
Identifiable signs of infections assist in determining the mode of treatment. Some organisms have a predilection for the fetoplacental unit and the neonate.
Body substance isolation should be used for all infectious patients; reverse isolation of visitors may be needed to protect the immunosuppressed patient.
Reduces risk of cross contamination because gloves may have noticeable defects, get torn or damaged during use.
Most infections do not pose serious problems to the mother but can have varying effects on the fetus. Ascending tract infections have a greater chance of resulting in neonatal bacteremia and pneumonia
INTERVENTION
RATIONALE
Antipyretic is a substance used to reduce fever. It causes the hypothalamus to override a prostaglandin-induced increase in temperature. Once administered, the body will then work to lower the temperature which would result in reduction of fever.
A fever causes the body to lose water, which may result in dehydration. Dehydration may worsen fever, which then would further exacerbate dehydration. If left unattended, the cycle will continue and may aggravate one’s condition.
Dependent:
Administer antipyretic drugs as prescribed by the doctor.
Administer fluids through IV to prevent dehydration.
Collaborative:
Refer to Obstetrician-Gynecologist
After nursing intervention, the patient will verbalize a reduction of pain on her lower abdomen.
Intervention
and
Rationale
INTERVENTION
RATIONALE
Perform pain assessment each time pain occurs. Document and investigate changes from previous reports and evaluate results of pain interventions.
Work with patient to prevent aggravation of pain. Instruct patient to report pain immediately if sensed.
Administer analgesics, as indicated by the doctor.
To demonstrate improvement in status or to identify worsening of underlying condition/developing complications
Timely intervention is more likely to be successful in alleviating pain.
Analgesics are medications designed to relieve pain. Administering this medication may help maintain acceptable level of pain.
After 1 week of nursing intervention, the patient is not at risk of infection AEB normal findings on her lab tests.
After the nursing intervention the patient will remain free of infection as evidenced by normal vital signs.
Intervention
and
Rationale
INTERVENTION
RATIONALE
Repeat lab urinalysis
Encourage hand hygiene and educate the patient the importance of proper hand hygiene
Educate the patient about the transmission and complications
Educate the visitors to use surgical mask or instruct the visitors to cover mouth and nose during coughing and sneezing
Abnormal findings on a urinalysis may prompt repeat testing to see if the results are still abnormal and/or may be followed by additional urine and blood tests to ensure patient's well-being
Hand washing is one of the best way to prevent infection
Educating the patient about her condition can raise patient's awareness and understanding
Educating visitors on the importance of preventing droplet transmission and to reduce the risk of infection
Evaluation
After 45 mins - 1 hour of nursing intervention, the patient displayed a body temperature within normal range.
After nursing intervention, the patient verbalized a reduction of pain on her lower abdomen.
After 1 week of nursing intervention, the patient is not at risk of infection AEB normal findings on her lab tests.