case study: a bicornuate uterus jamie banner, meghan...

Running head: Case Study: A Bicornuate Uterus 1

Case Study: A Bicornuate Uterus

Jamie Banner, Meghan Gilroy, and Ashley Hawk

Kent State University Stark

College of Nursing

Fall 2010


In this case study we plan to show the risks associated with a uterine anomaly,

such as a bicornuate uterus, and the outcomes associated with our patient and the

newborn. We picked this patient because of her uterine anomaly and the implications it

held for her pregnancy. Throughout this case study we plan to present the specific

information related to this patient and the risks associated with the patient and the

newborn.

Patient History

Our patient, CE, delivered a baby girl by cesarean section on September 24,

2010 at 11:49 am. She is a gravid one para one, which means this is her first pregnancy

and she carried the pregnancy longer than twenty weeks. She attended prenatal

classes and decided she was going to breastfeed after delivery. She had a regional

spinal anesthetic with delivery at thirty-nine weeks and six days. Her last menstrual

period was December 19, 2009, making her estimated date of delivery September 26,

2010. She did not have any complications during pregnancy although she does have a


bicornuate uterus, which is a disorder of the uterus that divides it in half with a septum

and makes it into a heart shape, as seen below.

MRI Image of Bicornuate Uterus (Fajardo & DeAngelis, 2006).

Table 1.0 Patient History

Allergies mold, shellfish

Religion not stated

Education masters, teacher

Smoker previously (quit 1 yr ago with a history of

2yrs)

Alcohol Use none

Substance Abuse none

Significant Family History Grandfather had diabetes

Significant Medical/Surgical History Asthma, Bicornuate uterus, Septum in

uterus repaired

Having a bicornuate uterus usually means that the ability to hold a pregnancy to

term is not possible (Nordhaus-Bike, 1997). It is an anomaly of the mullerian duct where

the top part of the uterus is split in two with a septum and the bottom part is one cavity.


The problem then occurs when the embryo implants into the top part of the uterus on

either side and then as the fetus grows it runs out of room because the uterus cannot

expand as much with a septum down the middle (Fajardo & DeAngelis, 2006). This

often results in spontaneous abortion of the pregnancy in the first or second trimesters.

Most of the time women do not know they have a uterine anomaly until they seek

medical help for infertility (Nordhaus-Bike, 1997). A bicornuate uterus can be diagnosed

with a MRI of the pelvis (Fajardo & DeAngelis, 2006). A corrective surgery is available

to help women with uterine anomalies carry a pregnancy to term. Having a uterine

anomaly is associated with many factors that contribute to high risk pregnancy, such as

preterm labor, premature rupture of membranes, breech presentation, placental

abruption, and low birth weight. Zlopasa, Skrablin, Kalafatic, Banovic, and Lesin (2007)

found contradicting results regarding the use of corrective surgery for patients with

uterine anomalies although the study did show that the incidence of spontaneous

abortion in these patients decreased after corrective surgery. CE had corrective surgery

to her uterus with repair of the septum which leads to me think that she had a partial

bicornuate uterus where she has one vagina, cervix, and lower uterine segment and two

upper segments of the uterus (Fajardo and DeAngelis, 2006). Because of the high risk

effects during pregnancy associated with a bicornuate uterus we decided to use this

patient for further study.

Prenatal Data

Table 2.0 Prenatal Lab Data

Test Patient Values

Normal Values Analysis


Rh

positive

positive or negative

Rh factor is tested to determine if a woman is Rh negative to prevent hemolytic disease in the newborn in subsequent pregnancies. The drug that is given to prevent this is RhoGAM. Blood type is tested for transfusions.

Type O O,A, B, AB

Hematocrit 35.9% 34-45% in pregnancy

Low levels of hematocrit can result in anemia. This is common because the fetus has a high demand for iron. Patient with lo hematocrit may need to an iron supplement.

Hemoglobin 12.7 g/dL 12-16 g/dL

Hemoglobin is the protein molecule in red blood cells that carries oxygen from the lungs to the body's tissues and returns carbon dioxide from the tissues to the lungs. Her level is normal.

VDRL nonreactive nonreactive This test is used to screen for syphilis and reagin.

Rubella immune immune

The rubella vaccine is a live virus. Although it is available as a single preparation, it is recommended that it be given as part of the MMR vaccine, which protects against measles, mumps, and rubella (German measles) or the MMRV vaccine (MMR plus varicella (chickenpox) vaccine) when age-appropriate.

Urine C and S

negative negative

The test is used to diagnose a urinary tract infection. Pregnant women without any symptoms may


be screened for bacteria in their urine, which could affect the health and development of the fetus.

Sickle cell not applicable

negative

This is a recessive autoimmune disorder in which normal adult hemoglobin is abnormally formed. This is primarily in African American decent, and occasionally in people of southeast Asian or Mediterranean origin.

Chlamydia negative negative

Chlamydia is the most common bacterial sexually transmitted infection in the US. Transmission commonly occurs through Vaginal sex. The recommended treatment is azithromycin 1g orally or doxycycline 100mg by mouth for 7 days. They are tested after the treatment and if still positive they will get another treatment.

Gonorrhea is the second most common sexually transmitted infection in the US. It is also transmitted through intercourse. The most common treatment is a mix of azithromycin and amoxacillian.

Gonorrhea negative negative

Pap test normal normal

This test is to screen for cellular abnormalities by obtaining a sample containing ceils from the cervix and the endocervical canal. Precancerous and cancerous conditions, as well as a typical finding and inflammatory changes.


Triple screen

declined

α-fetalprotein

1-4 g/L at 13-14 weeks

The triple screen measures not only α-fetalprotien, but β-hCG. α-fetalprotein is an antigen produced in the fetal liver and whose level in amniotic fluid can be used to detect certain fetal abnormalities, including Down syndrome and spina bifida. β-hCG is a hormone excreted during the development of an embryo or fetus.

β-hCG

Up to 500,000 IU/L in the first trimester

1 hour glucose tolerance

107 Level lower than 130

A one hour glucose tolerance test is routinely recommend between 24 and 28 weeks of pregnancy to check for gestational diabetes, a high blood sugar condition that some women get during pregnancy.

Prenatal lab data and analysis information obtained from (Davidson, London, & Ladewig, 2008).

Table 3.0 Prenatal Diagnostic Tests

Test Date Normal Values Patient Findings

Amniotic fluid 5/6/10 Normal All structures normal

Diagnostic test analysis information obtained from (Davidson, London, & Ladewig, 2008).

The amniotic fluid was tested on 5/6/10 by an ultrasound. At this time the fetus

was 19 weeks and 1 day old. After the amniotic fluid was tested all structures were

normal. During this time the placenta was posterior and the fetal heart rate was 154

beats per minute.

Prenatal Medications


The following are two medications that the patient was taking during pregnancy.

These medications were used to control her asthma symptoms on an as needed basis

and were not continued postpartum. It is important to control asthma symptoms during

pregnancy because maternal respiratory problems can cause problems for the fetus in

utero such as, intrauterine growth restriction, small for gestational age, and fetal

compromise (Prasad & Samuels, 2008). Intrauterine growth restriction occurs when the

uterus inhibits the fetus from growing any larger due to over distention which can create

a small for gestational age newborn, or a newborn that does not fit the height and

weight criteria according to the norms for that gestational age group (Davidson, London,

& Ladewig, 2008).

Table 4.0 Albuterol

Generic Drug Name:

Albuterol

Drug Classification:

bronchodilators

adrenergics

Location of metabolism/excretion:

Extensively metabolized by the liver and other tissues

Nursing Implications/Assessment:

Assess lung sounds, pulse, and blood pressure before administration and during peak of medication. Note amount, color, and character of sputum produced

Monitor pulmonary function tests before initiating therapy and periodically during therapy

Observe for paradoxical bronchospasm (wheezing). If condition occurs, withhold medication and notify health care professional immediately

Brand/Trade Names:

Accuneb

Half/Life:

Inhalation: 3.8 hr

Indications for use:

• Used as a bronchodilator to control and prevent reversible airway obstruction caused by asthma or COPD

• Inhaln: Used as a quick-relief agent for acute bronchospasm and for prevention of exercise-induced bronchospasm

Contraindications:

Hypersensitivity to adrenergic amines

OB: Lactation: Pedi: Safety not established for pregnant women near term, breastfeeding women, and children <2 yr

Onset/Peak/Duration for Insulin:

Key Patient Teaching Points:

Advise patients to use albuterol first if using other inhalation medications and allow 5 min to elapse before administering other inhalant medications unless otherwise directed

Advise patient to rinse mouth with water after each inhalation dose to minimize dry mouth

Instruct patient to notify health care professional if no response to the usual dose of albuterol or if contents of one canister are used in less than 2 wk

Instruct patient on how to use inhaler.


Action:

• Binds to beta2-adrenergic receptors in airway smooth muscle, leading to activation of adenyl cyclase and increased levels of cyclic-3', 5'-adenosine monophosphate. Increases in cAMP activate kinases, which inhibit the phosphorylation of myosin and decrease intracellular calcium. Decreased intracellular calcium relaxes smooth muscle airways

• Relaxation of airway smooth muscle with subsequent bronchodilation

• Relatively selective for beta2 (pulmonary) receptors

Adverse Reactions/Side Effects:

CNS: nervousness, restlessness, tremor, headache, insomnia (Pedi: occurs more frequently in young children than adults), hyperactivity in children. Resp: PARADOXICAL BRONCHOSPASM (EXCESSIVE USE OF INHALERS). CV: chest pain, palpitations, angina, arrhythmias, hypertension. GI: nausea, vomiting. Endo: hyperglycemia. F and E: hypokalemia. Neuro: tremor.

Routes and Dosage range for each route:

Inhalin (Adults and Children >12 yr): NIH Guidelines for acute asthma exacerbation via nebulization or IPPB—2.5–5 mg q 20 min for 3 doses then 2.5–10 mg q 1–4 hr prn; Continuous nebulization—10–15 mg/hr.

Evaluation criteria:

Prevention or relief of bronchospasm

Therapeutic Effects: (expected outcome) bronchodilation

Interactions: Concurrent use with other adrenergic agents will have increase adrenergic side effects

Labs to monitor (if applicable): May cause transient decrease in serum potassium concentrations with nebulization or higher-than-recommended doses.

All medication information provided by Davis’ Drug Guide 12e.

Table 5.0 Fluconazole

Generic Drug Name:

Fluconazole


antifungal


80% excreted unchanged by the kidneys; <10% metabolized by the liver


Assess infected area and monitor CSF cultures before and periodically during therapy

Specimens for culture should be taken before instituting therapy. Therapy may be started before results are obtained

Brand/Trade Names:

Diflucan

Half/Life:

Adults: 30 hr


PO: Single-dose oral treatment of vaginal

Contraindications:

Hypersensitivity to fluconazole or other azole antifungals

Concurrent use with



Instruct patient to take medication as directed, even if feeling better. Doses should be taken at the same time each day. Take missed doses as soon as remembered, but not if almost time for next


candidiasis pimozide dose. Do not double doses

Instruct patient to notify health care professional if skin rash, abdominal pain, fever, or diarrhea becomes pronounced, if signs and symptoms of liver dysfunction (unusual fatigue, anorexia, nausea, vomiting, jaundice, dark urine, or pale stools) occur, if unusual bruising or bleeding occur, or if no improvement is seen within a few days of therapy

Action:

Inhibits synthesis of fungal sterols, a necessary component of the cell membrane


CNS: headache, dizziness, seizures. GI: HEPATOTOXICITY, abdominal discomfort, diarrhea, nausea, vomiting. Derm: EXFOLIATIVE SKIN DISORDERS INCLUDING STEVENS-JOHNSON SYNDROME . Endo: hypokalemia, hypertriglyceridemia. Misc: allergic reactions,including anaphylaxis.


PO (Adults): 150-mg single dose; prevention of recurrence (unlabeled)—150 mg daily for 3 days then weekly for 6 mo


Resolution of clinical and laboratory indications of fungal infections. Full course of therapy may require weeks or months of treatment after resolution of symptoms

Prevention of candidiasis in patients who have undergone bone marrow transplantation

Decrease in skin irritation and vaginal discomfort in patients with vaginal candidiasis. Diagnosis should be reconfirmed with smears or cultures before a second course of therapy to rule out other pathogens associated with vulvovaginitis. Recurrent vaginal infections may be a sign of systemic illness

Therapeutic Effects: (expected outcome)

Fungistatic action against susceptible organisms

May be fungicidal in higher concentrations

Interactions:

Increase levels and risk of toxicity from cyclosporine, rifabutin, tacrolimus, theophylline, zidovudine, alfentanil, and phenytoin increase levels and effects of benzodiazepines, zolpidem, bispirone, nisoldipine, tricyclic antidepressants, and losartan

May increase risk of bleeding with warfarin

Labs to monitor (if applicable):

Monitor BUN and serum creatinine before and periodically during therapy; patients with renal dysfunction will require dose adjustment

Monitor liver function tests before and periodically during therapy. May cause increase AST, ALT, serum alkaline phosphate, and bilirubin concentrations


Labor and Delivery

Our patient was scheduled for a cesarean section because of her bicornuate

uterus and the breech presentation of the fetus. Because of her uterine anomaly, there

is less room for the fetus in the uterus, which often results in fetal malposition

(Gimovsky, Rosa, & Bronshtein, 2007). She had a regional spinal anesthetic for the

delivery on September 24, 2010. During the delivery process, she was receiving


lactated ringers through IV at 125mL/hr. When the fetus was delivered there was a

small amount of vernix caseosa present. Vernix caseosa is a cheeselike substance that

covers the fetus in the uterus and lubricates the skin (Davidson, London, & Ladewig,

2008).

The estimated blood loss during the delivery was 600mL and the total fluid loss

for delivery was 2100mL. After the delivery the lactated ringers was set to a wide open

rate to help compensate for some of the fluid loss during delivery. Shortly after pitocin

was started intravenously at 20units/min to help keep the fundus contracted. After

delivery if the fundus is not firm the patient is at risk for postpartal hemorrhage

(Davidson, London, & Ladewig, 2008). The lactated ringers was set for 125mL/hr and

ordered to be stopped twenty four hours after delivery.

Postpartum Assessment and Data

Upon entering the room in the morning, the patient was introduced to the student

nurse and was observed resting in her room holding her baby at the side of her bed.

She was by herself because her husband went to work but he was going to be coming

back that evening to take her home. She was bonding well with the baby throughout the

whole day holding her and talking to her. She asked many questions all day to the

nurses, the doctor, and the lactation consultant. She was asking about breast feeding,

washing her baby, cord care, and about her baby’s weight loss. Overall, the patient

showed a lot of affection and caring for her baby.

The patients vital signs, head to toe assessment and the BUBBLE HEB assessment

were performed. The results are as follows:


Table 6.0 Vital Signs

Pulse 62

Respirations 17

Temperature 97.9

Blood Pressure 110/68

Pain 5/10

All of these findings are within normal limits (Craven & Hirnle, 2009). Although

the patient’s pain was stated to be a 5/10, she said that the pain was a manageable

pain located in her abdomen.

Table 7.0 Neurological Assessment

Eyes open Spontaneously

Verbal Response Oriented

Motor Responses Moves all extremities

to command

PERL Present

Limb Movement

L arm Strong

R arm Strong

L leg Strong

R leg Strong

All neurological assessment findings are within normal limits (Craven & Hirnle, 2009).

Table 8.0 Cardiovascular Assessment


Apical Rate, Rhythm, and Intensity 62, regular and strong

Capillary Refill +2 bilaterally

Edema Bilaterally in legs, with +1 pitting

Homan’s Sign Negative bilaterally

The patient showed signs of pitting edema in her legs bilaterally which can be a

sign of fluid retention due to the effects of the cesarean section and the stress that is

placed on the heart (Davidson, London, & Ladewig, 2008). The patient was observed

for any worsening in the edema and encouraged to elevate her feet when lying or sitting

to promote blood flow back to the heart. All other findings are within normal limits

(Craven & Hirnle, 2009).

Table 9.0 Respiratory Assessment

Respirations No distress

Cough Absent

Rate 17 respirations/min

Breathing Pattern Regular

Breath Sounds Equal bilaterally

All respiratory assessment findings are within normal limits (Craven & Hirnle, 2009).

Table 10.0 Skin Assessment

Skin Character Normal

Skin Color Pink

Skin Temperature Warm


Incision Abdominal incision with steristrips closely approximated and

abdominal binder in place.

All skin assessment findings are within normal limits (Craven & Hirnle, 2009).

Table 11.0 Gastrointestinal/Genitourinary Assessment

Abdomen Soft

Bowel Sounds Present in all four quadrants

Last Bowel Movement During the night, around 0230

Urine color and character Clear and normal

Voiding Continent

Hemorrhoids None present

All gastrointestinal and genitourinary assessment findings are within normal limits

(Craven & Hirnle, 2009).

Table 12.0 Reproductive Assessment

Breasts Soft, non-tender

Nipples Normal with some tenderness due to breastfeeding

Fundal Height Midline at umbilicus

Lochia color and amount Rubra, scant amount

All reproductive assessment findings are within normal limits (Craven & Hirnle, 2009).

Table 13.0 Psychosocial Assessment

Anxiety level Mild

Evidence for Anxiety level Patient asking many questions about her baby and what to

expect when she goes home


Affection Appropriate; patient dealing well with having a new baby

All psychosocial assessment findings are within normal limits (Craven & Hirnle, 2009).

Table 14.0 BUBBLEHEB Assessment

Breasts Soft, filling and non-tender

Uterus Firm, midline and at umbilicus

Bladder Voiding adequately, with no sign of infection

Bowels Normal bowel movements have occurred

Bowel sounds in all four quadrants

Lochia Small amount rubra in color

Episiotomy/Lacerations No laceration or episiotomy noted

Homan’s Sign Negative bilaterally

Patient did have +1 edema with pitting in both lower legs.

Emotions

Patient was emotionally stable and dealing with being a first time mother very well. She was very excited about the whole process and experience of being a mom. She did show signs of having slight anxiety of taking the baby home and making sure she does everything right and that she is supposed to.

Bonding

The mom was bonding very well with the baby. She was talking to the baby, calling her by name and enfacing her baby. She explores her baby’s skin and touches with her fingers palms and enfolds the baby. The mom was also breast feeding her baby so was very good experience for bonding.

All findings are within normal limits (Davidson, London, & Ladewig, 2008).

Postpartum Laboratory Data


Table 15.0

Tests Normal Values Patient Results Analysis

Hemoglobin 12-16 g/dl 8.6

This level is low. A low hemoglobin is referred to as anemia. This makes sense for this patient because of her blood loss with the C-section.

Platelets 150-450 180

Platelet count is needed to determine the patients clotting factor or ability to stop bloodflow. Platelets clot the blood.

Hematocrit 34-45% 36.7%

Low levels of hematocrit can result in anemia. This is common because the fetus has a high demand for iron. Patient with low hematocrit may need to an iron supplement

Postpartum laboratory values were obtained from (Davidson, London, & Ladewig, 2008).

Postpartum Medications

This patient was ordered several medications postpartum to help control her pain

and combat low hemoglobin levels caused by the blood loss due to the cesarean

section. The orders read as follows:

Percocet (Acetaminophen 500mg, Oxycodone 7.5mg)—one tablet by mouth

every four hours. This medication is given to help control pain.


Naproxen (500mg)—one tablet by mouth twice daily. This medication is given to

help control pain.

Ferrous Sulfate (60mg)—one tablet by mouth daily. This medication is given to

help raise hemoglobin levels and prevent anemia.

Pitocin—20 units with 1000mL Lactated Ringers at 125mL/hr. This medication is

given to help the postpartal uterus contract to prevent postpartum hemorrhage.

The following tables are a detailed description of each medication and include

important information regarding the drug classification, action, side effects, indications

for use, and nursing implications related to that drug. All information gathered is used to

help the nurse understand the desired effect of the medication and any signs and

symptoms of adverse reaction in the patient.

Table 16.0 Acetaminophen/Oxycodone Combination

Generic Drug Name:

Acetaminophen

Oxycodone


opioid agonists nonopioid analgesic combinations


Mostly metabolized by the liver


Assess type, location, and intensity of pain prior to and 1 hr (peak) after administration. When titrating opioid doses, increases of 25–50% should be administered until there is either a 50% reduction in the patient's pain rating on a numerical or visual analog scale or the patient reports satisfactory pain relief. A repeat dose can be safely administered at the time of the peak if previous dose is ineffective and side effects are minimal

Assess blood pressure, pulse, and respirations before and periodically during administration. If respiratory rate is <10/min, assess level of sedation. Physical stimulation may be sufficient to prevent significant hypoventilation. Dose may need to be decreased by 25–50%. Initial drowsiness will diminish with continued use

Brand/Trade Names:

Percocet

Half/Life:

2-3 hr


Moderate to

Contraindications:

Hypersensitivity

Some products



Instruct patient on how and when to ask for and take pain medication

Medication may cause drowsiness or


severe pain contain alcohol or bisulfites and should be avoided in patients with known intolerance or hypersensitivity

Use Cautiously in:

OB

Lactation

dizziness. Advise patient to call for assistance when ambulating or smoking. Caution patient to avoid driving and other activities requiring alertness until response to medication is known

Advise patients taking Oxycontin tablets that empty matrix tablets may appear in stool

Advise patient to make position changes slowly to minimize orthostatic hypotension

Advise patient to avoid concurrent use of alcohol or other CNS depressants with this medication

Encourage patient to turn, cough, and breathe deeply every 2 hr to prevent atelectasis

Action:

Binds to opiate receptors in the CNS

Alters the perception of and response to painful stimuli, while producing generalized CNS depression


CNS: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams. EENT: blurred vision, diplopia, miosis. Resp: RESPIRATORY DEPRESSION. CV: orthostatic hypotension. GI: constipation, dry mouth, nausea, vomiting. GU: urinary retention. Derm: flushing, sweating. Misc: physical dependence, psychological dependence, tolerance.


PO (Adults B50 kg): 5–10 mg q 3–4 hr initially, as needed. Controlled-release tablets


Decrease in severity of pain without a significant alteration in level of consciousness or respiratory status

Therapeutic Effects:

Decreased pain

Interactions:

Use with caution in patients receiving MAO inhibitors (may result in unpredictable reactions decrease initial dose of oxycodone to 25% of usual


May increase plasma amylase and lipase levels


Table 17.0 Naproxen

Generic Drug

Name:

Naproxen


nonopioid analgesics

antipyretics

Location of

metabolism/excretion:

Mostly metabolized by

Nursing

Implications/Assessment:

Patients who have asthma, aspirin-

induced allergy, and nasal polyps are at


Brand/Trade

Names:

Aleve

Half/Life:

10-20 hr

the liver increased risk for developing

hypersensitivity reactions. Assess for

rhinitis, asthma, and urticaria

Assess pain (note type, location, and

intensity) prior to and 1–2 hr following

administration

Indications for

use:

Mild to moderate pain

Dysmenorrhea

Fever

Contraindications:

Hypersensitivity

Cross-sensitivity may occur with other NSAIDs, including aspirin

Active GI bleeding

Ulcer disease

Lactation: Passes into breast milk and should not be used by nursing mothers

Onset/Peak/Duration

for Insulin:


Instruct patient to take medication as

directed. Take missed doses as soon as

remembered but not if almost time for the

next dose. Do not double doses

May cause drowsiness or dizziness.

Advise patient to avoid driving or other

activities requiring alertness until response

to the medication is known

Caution patient to avoid the concurrent

use of alcohol, aspirin, acetaminophen, or

other OTC medications without consulting

health care professional. Use of naproxen

with 3 or more glasses of alcohol per day

may increase risk of GI bleeding

Action:

Inhibits

prostaglandin

synthesis

Adverse

Reactions/Side

Effects:

CNS: dizziness, drowsiness,

headache.

EENT: tinnitus, visual

disturbances.

Resp: dyspnea.

CV: edema, palpitations,

tachycardia.

GI: DRUG-INDUCED

HEPATITIS, GI BLEEDING,

constipation, dyspepsia,

nausea, anorexia, diarrhea,

discomfort, flatulence,

vomiting.

GU: cystitis, hematuria, renal

failure.

Derm: photosensitivity,

rashes, sweating,

pseudoporphyria (12%

incidence in children with

juvenile rheumatoid

arthritis—discontinue therapy

if this occurs).

Hemat: blood dyscrasias,

prolonged bleeding time.

Misc: ALLERGIC

REACTIONS INCLUDING

ANAPHYLAXIS AND

STEVENS-JOHNSON

SYNDROME .

Routes and Dosage

range for each route:

PO (Adults):

Naproxen—250–500 mg

twice daily (up to 1.5

g/day). Delayed-release

naproxen—375–500 mg

twice daily. Naproxen

sodium—275–550 mg

twice daily (up to 1.65

g/day).


Relief of pain

Improved joint mobility. Partial arthritic relief is usually seen within 2 wk, but maximum effectiveness may require 2–4 wk of continuous therapy. Patients who do not respond to one NSAID may respond to another

Reduction of fever

Therapeutic

Effects:

Interactions: Labs to monitor (if applicable):


Decreased pain

Reduction of

fever

Suppression of inflammation

Concurrent use with aspirin

decrease naproxen blood

levels and may decrease

effectiveness

increase risk of bleeding

with anticoagulants,

thrombolytic agents ,

eptifibatide, tirofiban,

cefotetan, cefoperazone,

valproic acid,

corticosteroids, clopidogrel,

and ticlopidine

Additive adverse GI side

effects with aspirin,

corticosteroids, alcohol,

and other NSAIDs

Probenecid increase blood

levels and may increase

toxicity

May increase risk of toxicity

from methotrexate,

antineoplastics, or radiation

therapy

May increase serum levels

and risk of toxicity from

lithium

Evaluate BUN, serum creatinine, CBC, and liver function tests periodically in patients receiving prolonged therapy

May increase serum potassium, BUN, serum creatinine, alkaline phosphatase, LDH, AST, and ALT tests levels. May decrease blood glucose, hemoglobin, and hematocrit concentrations, leukocyte and platelet counts, and CCr

Bleeding time may be prolonged up to 4 days following discontinuation of therapy


Table 18.0 Oxytocin

Generic Drug

Name:

Oxytocin


hormone

Location of


Rapidly metabolized by

liver and kidneys

Nursing


• Fetal maturity, presentation, and pelvic

adequacy should be assessed prior to

administration of oxytocin for induction of

labor

• Assess character, frequency, and duration

of uterine contractions; resting uterine tone;

and fetal heart rate frequently throughout

administration. If contractions occur <2 min

apart and are >50–65 mm Hg on monitor, if

they last 60–90 sec or longer, or if a

significant change in fetal heart rate

develops, stop infusion and turn patient on

her left side to prevent fetal anoxia. Notify

health care professional immediately

• Monitor maternal blood pressure and

pulse frequently and fetal heart rate

continuously throughout administration

• This drug occasionally causes water

Brand/Trade

Names:

Pitocin

Half/Life:

3–9 min


intoxication. Monitor patient for signs and

symptoms (drowsiness, listlessness,

confusion, headache, anuria) and notify

physician or other health care professional

if they occur

Indications for

use:

• IV: Induction of

labor at term

• IV: Facilitation of

threatened abortion

• IV, IM:

Postpartum control

of bleeding after

expulsion of the

placenta

Contraindications:

• Hypersensitivity

• Anticipated nonvaginal delivery

Onset/Peak/Duration

for Insulin:


Advise patient to expect contractions similar to menstrual cramps after administration has started

Action:

• Stimulates uterine smooth muscle, producing uterine contractions similar to those in spontaneous labor

• Has vasopressor and antidiuretic effects

Adverse

Reactions/Side

Effects:

CNS: maternal—COMA,

SEIZURES, fetal—

INTRACRANIAL

HEMORRHAGE.

Resp: fetal—ASPHYXIA,

hypoxia.

CV: maternal—hypotension,

fetal—arrhythmias.

F and E: maternal—

hypochloremia,

hyponatremia, water

intoxication.

Misc: maternal increase

uterine motility, painful

contractions, abruptio

placentae, decrease uterine

blood flow, hypersensitivity.

Routes and Dosage


Induction/Stimulation of Labor

IV (Adults): 0.5–2

milliunits/min; increase by 1–2

milliunits/min q 15–60 min until

pattern established (usually 5–

6 milliunits/min; maximum 20

milliunits/min), then decrease

dose.

Postpartum Hemorrhage

IV (Adults): 10 units infused at

20–40 milliunits/min.

IM (Adults): 10 units after

delivery of placenta.


• Onset of effective contractions

• Increase in uterine tone

• Reduction in postpartum bleeding

Therapeutic

Effects:

• Induction of labor

• Control of postpartum bleeding

Interactions:

• Severe hypertension may

occur if oxytocin follows

administration of

vasopressors

• Concurrent use with

cyclopropane anesthesia

may result in excessive

hypotension


• Monitor maternal electrolytes. Water retention may result in hypochloremia or hyponatremia


Table 19.0 Ferrous Sulfate


Generic Drug

Name:

Ferrous Sulfate


Antianemics; Iron

supplements

Location of


Mostly recycled, small

daily losses occurring

via desquamation,

sweat, urine, and bile.

Nursing


Assess nutritional status and dietary

history to determine possible cause

of anemia and need for pt teaching;

Assess bowel function for

constipation or diarrhea. Notify

health care professional and use

appropriate nursing measures should

these occur.

Brand/Trade

Names:

ED-IN-SOL, Fe50,

Fesol, Feratab, Fer-

gen-sol, Fer-In-Sol,

Fer-Iron, Slow FE

Half/Life:

N/A

Indications for

use:

PO: Treatment

and prevention of

iron deficiency

anemia.

Contraindications:

Anemia not due to iron

deficiency;

Hemochromatosis;

Hemosiderosis;

Hypersensitivity to iron

products; Use

cautiously in: Peptic

ulcer disease;

Ulcerative colitis or

regional enteritis

(condition may be

aggravated);

Alcoholism; Severe

hepatic impairment;

Severe renal

impairment.

Onset/Peak/Duration

for Insulin:

PO: 4 days/ 7-10 days/

2-4 mo; (effects on

erythropoiesis).


Explain purpose of iron therapy to pt;

Encourage pt to comply with medication

regimen. Take missed doses as soon as

remembered within 12 hr; otherwise,

return to regular dosing schedule. Do not

double doses; Advise pt that stools may

become dark green or black; Instruct pt to

follow a diet high in iron; Discuss with

parents the risk of a child overdosing on

iron. Medication should be stored in the

original childproof container and kept out

of reach of children. Do not refer to

vitamins as candy; In the event of a

suspected overdose, parents should

contact poison control center (1-800-222-

1222) or emergency medical services

(911) immediately.

Action:

An essential

mineral found in

hemoglobin,

myoglobin, and

many enzymes;

Enters the

bloodstream and is

transported to the

organs of the

reticuloendothelial

system (liver,

spleen, bone

marrow) where it

becomes part of

iron stores.

Adverse

Reactions/Side

Effects:

CNS: dizziness,

headache, syncope;

GI: nausea,

constipation, dark

stools, epigastric

pain, GI bleeding,

vomiting; Misc:

temporary staining of

teeth (liquid

preparations).

Routes and Dosage


Oral iron dosages are

expressed as mg of

elemental iron. Multiple

salt forms exist—see

approximate equivalent

doses below or consider %

elemental iron of each salt

for dose conversions.

Approximate Equivalent

Doses (mg of iron salt):

Ferrous fumarate—197;

Ferrous gluconate—560;

Ferrous sulfate—324;

Ferrous sulfate

exsiccated—217.

PO (Adults): Deficiency- 2-

3 mg/kg/day in 2-4 divided

doses or 60-100 mg

elemental iron twice daily;


Increase in hemoglobin, which

may reach normal parameters

after 1-2 mo of therapy. May

require 3-6 mo for normalization

of body iron stores; Improvement

in or prevention of iron deficiency

anemia.

Therapeutic

Effects:

(expected

Interactions:

Drug-Drug: ↓ absorption of

tetracyclines,

fluoroquinolones


Monitor hemoglobin, hematocrit,

and reticulocyte values prior to


outcome)

Resolution or

prevention of iron

deficiency

anemia.

bisphosphonates,

levothyroxine,

mycofenolate mofetil, and

penicillamine

(simultaneous

administration should be

avoided); ↓ absorption of

and may ↓ effects of

levodopa and methyldopa;

Concurrent administration

of proton pump inhibitors,

histamine H2 antagonists,

and cholestyramine may ↓

absorption of iron; Doses

of ascorbic acid ≥ 200 mg

may ↑ absorption of iron by

up to 30%;

Chloramphenicol and

vitamin E may ↓

hematologic response to

iron therapy.

Drug-Food: Iron absorption

is ↓ 33-50 % by concurrent

administration of food.

Prophylaxis- 60-100 mg

elemental iron daily. and every 3 wk during the first 2

mo of therapy and periodically

thereafter. Serum ferritin and iron

levels may also be monitored to

assess effectiveness of therapy;

Occult blood in stools may be

obscured by black coloration of

iron in stool. Guaiac test results

may occasionally be false-

positive Benzidine test results are

not affected by iron preparations.


Postpartum Treatments

The patient had an incision from her caesarian section that was being held

together using steristrips along with an abdominal binder to help with keeping the

incision together. The patients iron level was 8.6 so she was given an iron supplement

as a treatment for this. After a woman has a baby her iron levels typically drop because

of the amount of blood that is lost throughout the delivery (Davidson, London, &

Ladewig, 2008).

Table 20.0

Postpartum Nutritional Assessment

Physical Appearance: Groomed and clean

Pre-pregnancy weight: 124lbs


Total weight gain during pregnancy: 40lbs (equaling 164lb total)

Desired weight to return to: 120lbs

Exercise pattern: Regularly

Laxatives/Stool softeners: Not used

Racial/ Ethnic considerations in diet: None

Concerns about Nutritional habits: What type of foods, if any, would affect the

baby because she was breast feeding.

Family history diseases related to

nutrition: Grandfather had diabetes

Who shops for the groceries: The patient

Who cooks in the household: The patient

Snack Pattern: Snacks on apples and chips and salsa

Food Stamps/WIC: No

Breast or Bottle feeding Breast Feeding

In the past 24 hours that patient has had for breakfast; two eggs, a bagel with

peanut butter and a glass of water. At lunch, she had a serving of pasta, a roll, and a

glass of water. For dinner, she had a grilled chicken Caesar salad, a roll and a 12 oz.

can of Pepsi. Throughout the day the patient drank glasses of water and had cups of ice

cubes.

Newborn History

The baby was born on September 24, 2010 at 11:49am. She was born at 6

pounds and 11 ounces or 3,033.5 grams and 19 ½ inches long at 39 weeks and 6 days

gestation. The baby was delivered by a caesarean section because she was in a breech


position. When the residents delivered the baby, the cord was wrapped around the neck

three times, but there was no sign of distress from the baby. During the caesarean

section, the mother and baby’s blood did not mix. Also, the baby’s blood type is B-, so

there was no RhoGAM injection needed for the mother. However, a RhoGam injection

would be needed if the mother’s Rh factor was negative and the newborn’s Rh factor

was positive to avoid antibody formation in the mother (Davidson, London, & Ladewig,

2008). The APGAR scores after she was born were 9 at 1 minute and 10 at 5 minutes.

The baby’s bilirubin level was 7.1, so she had good coloring of the skin.

Newborn Assessment

On the third day post-op, the mother and baby were doing well. The baby

weighed 6 pounds and 2 ounces bringing her total weight loss to 8.7% after delivery. A

normal range for weight loss in a term infant is 5-10% (Davidson, London, & Ladewig,

2008). The temperature was 98.3° Fahrenheit, or 36.8° Celsius. The baby’s heart rate

was 126 beats per minute and respirations were at a 36 respirations per minute. These

findings were on the lower end of the range because the baby had just been fed about a

half hour beforehand and was sleeping during the assessment (Davidson, London, &

Ladewig, 2008). The skin was warm, pink with normal, even coloring all around the

baby with normal skin turgor. The head fontanels were soft, even, and level. The ears

were fully formed and level with the head. The eyes of the baby were symmetrical and

even with the rest of the facial features. The newborn’s face was symmetrical all around

and there were no marks or bruising on the face from delivery. The assessment of the

mouth, the mucus membranes were pink, moist and clear so there were no problems

with feedings at all. This baby was breastfeeding and doing it well. She was getting


plenty of colostrum from the mother and was very content after her feedings. The

respirations were clear and even bilaterally with unlabored breaths. During this

procedure I heard that the cry was a vigorous one. The baby had no problems with

breathing due to any amniotic fluid in the lungs. Heart sounds for this baby were at a

regular pulse and capillary refill was present being less than three seconds. The

abdomen was soft and non-distended. There were bowel sounds present in all four

quadrants. The diaper was changed because she had a bowel movement that was

dark-brown in color. At this time it was noted that the genitals were fully developed and

patent. The bowels were working properly with no complications to voiding at all. The

umbilical cord was drying and cord care was done. For cord care, the area around the

cord was wiped with an alcohol swab to clean it, and then two to three drops of alcohol

were placed directly on the cord (Davidson, London, & Ladewig, 2008). The extremities

were symmetrical and the baby had full range of motion of her neck, hands, arms, legs

and feet, with no restrictions noted.

The Moro, suck, grasp, rooting, and Babinski reflexes were all present bilaterally.

According to Davidson, London, and Ladewig (2008) the Moro reflex is when the

newborn is startled and they straighten out their arms and hands, while the knees flex

and the extremities then slowly return to normal. The sucking reflex happens when an

object is placed into the newborn’s mouth and they start to suck on it. The grasp reflex

is when someone places their finger or an object into the newborns palm and they will

grasp it firmly. The rooting reflex happens when the side of the mouth or cheek is

touched and the newborn will turn their heads towards that side. The Babinski reflex

occurs when the toes will fan out and hyperextend and the big toe will dorsiflexion. This


follows after the bottom of the newborn’s foot is stroked from the heel up to and across

the ball of the foot (Davidson, London, & Ladewig, 2008).

The patient declined the Hepatitis B injection for the baby. This vaccine is

recommended by the World Health Organization as part of an effort to reduce the

amount of infant deaths due to perinatal infection and infection from another member of

the household (World Health Organization, 2008).

Nursing Diagnoses: Maternal and Newborn

Physiological: Risk for postpartum hemorrhage related to over-distention of the

uterus as evidenced by bicornuate uterus.

Nutritional: Risk for potentional imbalanced nutrition related to inadequate

breastfeeding as evidenced by newborn weight loss of 8.6%.

Educational: Enhanced readiness to learn related to first time motherhood as

evidenced by patient asking questions about newborn care.

Psychological: Risk for low self esteem related to post pregnancy body image as

evidenced by patient stating plan of exercise routine.

Nursing Diagnosis:

Risk for postpartum hemorrhage related to over-distention of the uterus as evidenced by bicornuate uterus.

Goal: Patient will change perineal pads every four hours without saturation during my shift. By discharge, patient will understand and verbalize signs and symptoms of postpartum hemorrhage.

Interventions:

1. Intervention: Assess fundal height and tone every shift and as needed. Rationale: One of the most common signs of early postpartum hemorrhage is uterine atony (Davidson, London, & Ladewig, 2008). If the fundus is boggy, massage until firm and assess


patient for other signs and symptoms of hemorrhage. 2. Intervention: Assess color and amount of lochia on perineal

pad. Rationale: Lochia should not contain large, dark red clots and should decrease in amount each day postpartum; color should be red two to three days postpartum and turn pink to white up to two weeks postpartum (Davidson, London, & Ladewig, 2008).

3. Intervention: Teach patient the signs and symptoms of late postpartum hemorrhage such as occurrence of lochia rubra that does not decrease in amount and subinvolution of the fundus. Rationale: Late postpartum hemorrhage occurs most often when placental tissue is retained after delivery or infection occurs which causes bleeding because the uterus does not contract where the placental part is still attached (Davidson, London, & Ladewig, 2008).

4. Intervention: Assess and teach patient the signs and symptoms of anemia. Rationale: Anemia can occur due to excessive blood loss postpartally or during the delivery process. It is important for the patient to understand and be assessed for signs and symptoms of anemia, such as fatigue, headache, thirst, and orthostatic changes in blood pressure (Davidson, London, & Ladewig, 2008).

Evaluation: During my shift the patient did not saturate perineal pads in a four hour time period. The patient also verbalized signs and symptoms of postpartum hemorrhage.

Nursing Diagnosis:

Risk for potentional imbalanced nutrition related to inadequate breastfeeding as evidence by infant losing 8.6% body weight.

Goal: By the end of my shift the patient will verbalize newborn latched for at least fifteen minutes on each breast. By the newborns’ one week appointment the infant will have regained weight loss.

Interventions:

1. Intervention: Collaborate with clinical dietitian to set calorie, volume, and weight gain goals for the infant. Rationale: Collaboration with a dietician to assess weight gain goals is necessary for infants at risk (Davidson, London, & Ladewig, 2008).

2. Intervention: Collaborate with parents about effective breast feeding techniques that can be used with this infant. Rationale: Collaboration with parents from the beginning on needs and priorities is crucial to establishing effective feeding patterns (Kronborg & Vaeth, 2009).

3. Intervention: Promote consistency in approach to feeding. Rationale: Environmental factors can contribute to ineffective feeding patterns (Kronborg & Vaeth, 2009).


4. Intervention: Encourage parents to keep a journal of breastfeeding times and duration. Rationale: Knowing the amount of milk the infant is getting will help further intervention feeds (Davidson, London, & Ladewig, 2008).

Evaluation: At the end of my shift the patient verbalized that the newborn latched for fifteen minutes on each breast. At the newborns’ one week appointment weight gain/loss will be assessed.

Nursing Diagnosis:

Enhanced readiness to learn related to first time motherhood as evidenced by patient asking questions about newborn care.

Goal: The patient will demonstrate proper newborn care by the end of my shift. Before discharge the patient will verbalize comfort level in performance of newborn care.

Interventions:

1. Intervention: While describing how newborn care is done, have the patient demonstrate the care as it is explained. Rationale: Having the patient do the care while there is a nurse there will help them feel more confident and able to ask questions so they will be able to do it on their own (Davidson, London, & Ladewig, 2008).

2. Intervention: Give the patient written instructions about proper newborn care and why it’s important with a number to call, if needed. Rationale: While the nurse is giving the patient all of the instructions, there will always be something that the patient will have trouble remembering, and this way, there are papers to look at if they are unsure (Davidson, London, & Ladewig, 2008).

3. Intervention: Explain proper cord care and the importance of doing it with every diaper change and letting the cord fall off on its own. Rationale: Giving proper instructions will help the patient feel confident doing the cord care and help with the healing of the umbilicus and surrounding area (Davidson, London, & Ladewig, 2008).

4. Intervention: Explain the signs and symptoms of an infection, to be aware of while taking care of the newborn. Rationale: Being aware of what to look for, the patient will be able to catch an infection early so it can be treated properly. This will also help the newborn heal properly (Davidson, London, & Ladewig, 2008).

Evaluation: At the end of my shift patient demonstrated proper newborn care. At discharge the patient verbalized confidence in performing newborn care.


Nursing Diagnosis:

Risk for low self esteem related to post pregnancy body image as evidenced by patient stating weight desires.

Goal: By the end of my shift patient will verbalize understanding of realistic expectations of a postpartum body. The patient will verbalize positive aspects of self and set a realistic weight goal by discharge.

Interventions:

1. Intervention: Be supportive and nonjudgmental about the patients feelings. Rationale: Patient must feel comfortable before other interventions can be effective (Davidson, London, & Ladewig, 2008).

2. Intervention: Encourage good physical habits. Rationale: This will help the patient feel better and get information on healthy weight loss (Davidson, London, & Ladewig, 2008).

3. Intervention: Assist patient in redefining negative expressions. Rationale: Strategies focus on helping the person reexamine negative feelings about self and identifying positive attributes (Davidson, London, & Ladewig, 2008).

4. Intervention: Encourage patient to meet a nutritionist. Rationale: Learning healthy food and exercise habits will help benefit self esteem (Davidson, London, & Ladewig, 2008).

Evaluation:

By the end of shift the patient verbalized plans for changing diet and exercise to help her with a healthy weight loss and verbalized body expectations postpartum. At discharge the patient set a realistic weight goal and verbalized more comfort with her current body shape.

Conclusion

In conclusion, this case study has proven to be a great learning experience. We

have learned more about the effects of a uterine anomaly on pregnancy and the

possible complications associated with the patients’ specific uterine anomaly. It would

have been beneficial to inquire with the patient more about her uterine anomaly and

exactly when she found out about it. It would have also been beneficial to investigate

more with the patient about her attempts to get pregnant because it would have made it

easier to understand the reasoning behind the surgery to repair the septum in her

uterus. Without this information we can only make an educated guess about the

reasoning behind this surgery.


Another piece of the patient’s care that was overlooked was her spiritual care.

Although the patient did not volunteer information about her spirituality it would have

been beneficial to inquire about this because it would have allowed us to provide her

with competent care while being sensitive to her spiritual needs.

Overall the prognosis of the patient and newborn are great. Both seemed to be

doing well and the patient was adjusting well to her role as a new mother. As long as

the discharge instructions are followed properly and follow-up visits are maintained with

the respective physicians, the newborn and mother will do fine.


References

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Philadelphia: Wolters Kluwer Health| Lippincott Williams & Wilkins.

Davidson, M., London, M., & Ladewig, P. (2008). Olds' Maternal-Newborn Nursing &

Women's Health Across the Lifespan (8th ed.). Upper Saddle River, New Jersey:

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Kronborg, H., & Vaeth, M. (2009). How Are Effective Breastfeeding Technique and

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Contemporary OB/GYN , 28-35.

Taber's Cyclopedic Medical Dictionary. (2010). (21st e). F. A. Davis Company.


World Health Organization. (2008). Worldwide implementation of hepatitis B vaccination

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Zlopasa, G., Skrablin, S., Kalafatic, D., Banovic, V., & Lesin, J. (2007). Uterine

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