Case Overview Lexi Question & Answer Guide (With Explanation)
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Original Question
Case Overview: Lexi Cowslip is a 37-year old G3 P2 at 15 weeks gestation. She arrives at her 15-week OB appointment where she will have an amniocentesis done due to advanced maternal age. Prior to the procedure she has verbalized that she is anxious to have the procedure done and more anxious about hearing the results, when they are available. DocuCare Activity/Assignment Prep: Review the Clinical Decision Support Tool (Green Lippincott Advisor links) provided throughout your patient’s chart: Pregnancy (2nd Trimester, normal) Amniocentesis, assisting Lidocaine O’Meara, A. Lexi Cowslip. Maternity, newborn, and women’s health nursing: A case-based approach. Philadelphia, PA: Wolters Kluwer. Review this patient’s chart including Patient Information, Notes, Diagnostics, Vital Signs, and Current Orders Activities/Assignments: Part One: Clinical Judgment Activity You have received report from the antepartum nurse regarding Mrs. Cowslip, who has just undergone amniocentesis. You introduce yourself to Mrs. Cowslip and notice that she has tear stains on her face, and her eyes are reddened. She is gripping a used Kleenex in her hands. The following verbal exchange takes place: Nurse (You): “Are you having any pain or cramping Ms. Cowslip?” Lexi: “No” Nurse (You): “What about bleeding or leaking of fluid from your vagina?” Lexi: Shaking her head back and forth, “No” Lexi: “Do you know when I will get the results of the amino? I’m glad it is over with, but I am anxious to hear the results” Nurse (You): “I’m sorry I don’t know when they will be ready. I know your OB will call you to discuss the results” Lexi: “I knew I wanted three children, but what if I waited too long? What if I’m too old and my baby has a genetic disease? It would be my fault.” Assignment 1.1: Create a nursing care plan using the priority nursing diagnosis for this patient at this time. Use the above information to determine the priority nursing diagnosis. Document the care plan using the Nursing Dx > Create Care Plan Using NANDA Diagnosis tab. Include the following in your nursing care plan: Assignment 1.2: Document a mental health assessment using the information provided above. Document this assessment in the Assessments > Mental Health area of the health record. Include the independent nursing interventions you are implementing at this time in response to the patient’s verbal statements provided above in the additional notes area of the mental health assessment. Part Two: Clinical Judgment Activity Analyze Mrs. Cowslip’s electronic record, including data you have entered. Use the data to answer the following questions. Assignment 2.1: Document the answer to the following questions in the Notes section>Nursing Note-Progress Note. What information is relevant? (Recognizing Cues/Assessing) What does it make you think? What is the priority in this patient situation? (Analyzing cues & Prioritize Hypotheses/Assessing & Diagnosing) What nursing interventions are indicated? (Generate Solutions/Planning) What action should you take? (Take Action/Implementing) Part Three: You obtain a set of vital signs and complete a focused maternal assessment on Mrs. Cowslip. Assignment 3.1: Document the following findings in Mrs. Cowslip’s chart. Maternal specific data should be placed using the Maternity > Labor Vital Signs area of the electronic health record. BP: 110/70, HR 80, RR 20, O2 Sats 99%, 98.6 °F Pain: Denies pain at this time, 0/10. Pt alert and oriented to person, place and time, states feeling more “at peace” S1S2, regular heart sounds, pulses +2 and equal, no edema noted, cap refill < 3 seconds, skin warm and intact Patient denies cramping, leaking of fluid or bleeding. No drainage on peri pad. Gravid abdomen, soft, non-tender, band aid to right middle quadrant clean, dry, intact External contraction monitor in place, no contractions on monitor strip, resting tone soft Doppler fetal heart rate 160, no decelerations during auscultation Part Four: You review your assessment findings with the OB provider, who clears Mrs. Cowslip for discharge. The provider asks you to review post amniocentesis warning signs that require healthcare intervention with the patient. Assignment 4.1: Utilize the Patient Teaching tab to document the patient education you would provide regarding the post procedure warning signs requiring healthcare intervention. When documenting your patient teaching, include the following: Teaching Topic: Learning Objectives - make them "SMART" Learner(s) Readiness to Learn Teaching Methods Evaluation Continued Needs Additional Notes - if applicable Debriefing Questions: Upon completing the debrief questions submit them in Canvas How did you feel while completing this assignment? What went well and what did you struggle with during these activities? Does a woman's age affect her ability to have a "normal" pregnancy? Why or Why not? In the future when caring for a patient with anxiety, what objective and subjective data would identify whether or not a patient is managing their anxiety? How would you have responded to the statements made by Mrs. Cowslip? In the future, how will you "be present" with the patient as you provide nursing care?
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