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Boyle, Emily

Sex:F Weight:
Age: 19 Y Height:

MRN:9552028 Room:328 Health Care Provider: N Loose,MD
Code Status: 00 Isolation: 00 Food Allergies: NKA Diet: 00
Alerts: 00 Drug Allergies: NKA Env. Allergies: NKA
Hospital Floor:
Women's Health
Student: Astrid NicolauAssignment: Boyle, Emily: LaborSubmitted: 04/26/2014 09:15
Case Study Assignment Grading
Step 1: Case Study
Scenario No: 4018299
Title: Boyle, Emily: Labor
Short Description: Elsevier : WOMEN'S HEALTH :
Level 2, 75 minutes
Keywords: Epidural, Hypotension, Labor,
Fetal bradycardia, Basic
Description: Emily Boyle is a 19-year-old
primigravida who arrived to the
labor and delivery unit in active
labor 10 hours ago with the
father of the baby, Kevin. During
this case study, students will
have the opportunity to
document care for a laboring
patient, identify risks and
standards of care for a patient
receiving an epidural, and
prioritize interventions for a
laboring patient experiencing a
hypotensive event following
administration of an epidural.
Student Level: Intermediate
No. of Phases: 4
Objectives: 1. The student will identify
components of
individualized patient-
centered care by
documenting therapeutic
communication. statements
appropriate for the situation.
2. The student will function
competently as a member of
the health care team by
accurately documenting
findings. 3. The student will
use evidence based
practice to guide
assessment by identifying
standards of care for a
laboring patient with an
epidural. 4. The student will
promote safety for patient,
self, and others by
documenting appropriate
interventions for a laboring
patient experiencing a
hypotensive event caused
by an epidural.
Course: Maternity and Womens
Health
Topic: Labor
Step 2: Patient Profile

EHR Details
MRN Number: 4018299
Room Number: 328
Primary Diagnosis: Pregnancy, term
Secondary
Diagnosis:
Length of stay (Days): 7
Patient Details
First Name: Emily
Last Name: Boyle
Gender: F
Age: 19Years

Provider Details
First Name: Nancy
Admission Day: Tue
Admission Time: 06:00
Last Name: Loose
Credentials: MD
Step 3: Phase Information
Phase
#
Objective Information Start
Time /
Duration
0 You are the nurse caring for Emily Boyde, a
19 year-old gravida 1 para 0 who was
admitted at 0600 in active labor at term.
The father of the baby, Kevin, is at the
bedside and appears to be supportive.
Emily has had no prenatal care or prenatal
classes.
Emily is a 19 year-old female, gravida 1, para
0, in labor. She presented to the birthing unit at
0430 this morning with a history of no prenatal
care. She reports that she is 38 weeks, which is
consistent with ultrasound evaluation and
uterine size.

The father of the baby, Kevin, arrived with Emily
and has remained at her side.

Labor has progressed normally since arrival.
Emily received an epidural at 1600.
Tue 06:00
614
minutes
1 1. The student will document an
assessment of a laboring patient and fetus.
2. The student will identify whether findings
are within normal limits.
3. The student will identify stage and phase
of labor.
4. The student will identify standard of care
for a laboring patient with an epidural.
NOTE TO STUDENT:
You have 60 minutes to complete this phase.
Press the Pause button when not actively
charting.
To exit SimChart, press the Logout button in the
upper-right corner of the screen.

You are a labor and delivery nurse, assuming
care for Emily Boyle, a patient in active labor
with her first child.

You have already met Emily and a general
system assessment has already been
completed for her in the EHR.

You perform additional assessments.

Vital Signs:
Temperature: 97.6, forehead...
Blood Pressure: 126/72 mmHg, right arm,
lying...
Heart Rate: 76, radial...
Respiratory Rate: 18...
Oxygen Saturation: 99%, room air, digital
probe, finger...

[STUDENT ACTION: Document the patient's
vital signs.]

FHR is 136, monitor mode is external. FHR has
moderate variability and is positive for
accelerations, negative for decelerations.

Tue 16:15
60 minutes
Emily is 6 cm dilated, 100% effaced and fetal
station is 0. She is experiencing strong
contractions every 4 minutes, lasting 60
seconds. Monitor mode is external.

She reports her pain as 3 out of 10.

[STUDENT ACTION: Document the patient's
labor progress and her pain level.]

An IV is infusing lactated Ringer's at 125 mL/hr
and Emily drinks 250 mL of orange juice.

[STUDENT ACTION: Document the patient's
intake and add a nursing diagnosis and plan to
Emilys labor care plan.]

When you have finished the above tasks, click
Complete this Phase.
2 1. The student will document a pain
assessment.
2. The student will recognize the
significance of a fetal tracing that shows
bradycardia.

NOTE TO STUDENT:
You have 55 minutes to complete this phase.
Press the Pause button when not actively
charting.
To exit SimChart, press the Logout button in the
upper-right corner of the screen.

Emily complains that she still feels not really
pain, but a lot of pressure, discomfort, 2/10.

[STUDENT ACTION: Document this in the
EHR.]

You hear the monitor sounds decrease in
frequency. You observe the monitor and review
the tracing.

STUDENT ACTION: Document your
interpretation of the tracing in a Miscellaneous
Nursing Note.]

When you have finished the above tasks, click
Complete this Phase.
Tue 17:25
55 minutes
3 1. The student will document a labor
assessment.
2. The student will document patient
teaching related to fetal bradycardia.
NOTE TO STUDENT:
You have 60 minutes to complete this phase.
Press the Pause button when not actively
charting.
To exit SimChart, press the Logout button in the
upper-right corner of the screen.

You correctly responded to the emergent
situation by turning Emily on her side, starting
oxygen at 10 L/m by mask, increasing her IV
rate to deliver a 500 mL bolus, and assessing
Tue 18:25
60 minutes
her vital signs.

[STUDENT ACTION: Document these
interventions.]

You now find the following.
Vital Signs:
Blood Pressure: 92/48 mmHg, right arm, lying...
Heart Rate: 110, radial...
Respiratory Rate: 22
Oxygen Saturation: 97% on room air, digital
probe, finger...

[STUDENT ACTION: Document the vital signs.]

FHR is 110, monitor mode external with
minimal variability, absent accelerations and
present decelerations.

Emily Boyle's contractions are every 3 to 4
minutes, lasting 50-60 seconds. She reports
pain of 0/10 and lactated Ringer's is infusing at
150 mL/hr.

[STUDENT ACTION: Document the labor
progress assessment.]

Emily is anxious and scared. She asks you
what this means. Kevin is quiet. You provide
teaching about the cause and effect of the fetal
bradycardia, easing their concerns.

[STUDENT ACTION: Document the patient
teaching your provided.]

When you have completed the above tasks,
click Complete this Phase.
4 1. The student will document patient and
partner teaching and response to teaching.
NOTE TO STUDENT:
You have 60 minutes to complete this phase.
Press the Pause button when not actively
charting.
To exit SimChart, press the Logout button in the
upper-right corner of the screen.

You perform another assessment on Emily
Boyle.

Vital Signs:
Blood Pressure: 106/62 mmHg, right arm,
lying...
Heart Rate: 100, radial...
Respiration Rate: 22...
Oxygen Saturation: 98% on room air, digital
probe, finger...
Tue 19:30
60 minutes

[Student Action: Document the vital signs.]

FHR is 148, monitor mode external with
moderate variability, present accelerations and
absent decelerations. Emily's contractions are
every 3 minutes and last 50 seconds and are
strong. Emily is 7 cm dilated, 100% effaced and
fetal station is 0, right occiput anterior position.

Her pain is 0/10 and lactated Ringer's is
infusing at 150 mL/hr. Emily voids 350 mL clear
yellow urine.

[STUDENT ACTION: Document these
assessments.]

You have taught Kevin ways to help Emily focus
and ways to reposition her for comfort. Both
Kevin and Emily express gratitude for helping
him to feel a part of the delivery. You notice that
he now holds Emilys hand during contractions.

[STUDENT ACTION: Document and evaluate
your patient teaching.]

When you have completed the above tasks, you
may Complete and Submit the assignment.
Step 4: Student Documentation
Expand All Collapse All

Phase 1 Tue 16:15STUDENT EXCEEDED PHASE TIME
Student Charting
Vital Signs
Created By: A Nicolau Tue | 16:25
Temperature: 97.6 Site: Forehead
Pulse: 76 Site: Radial
Respiration: 18
BP Systolic: 126 Site: Right arm
BP Diastolic: 72 Position: Lying
Oxygenation: 99% Site: Digital probe, finger
Intake/Output
Created By: A Nicolau Tue | 16:28
Intake/Output: Intake
Type: Oral Intake
Description: PO fluids
Amount: 250
Unit: mL
Intake/Output
Created By: A Nicolau Tue | 16:28
Intake/Output: Intake
Type: Intravenous Fluids
Description: Lactated ringer's (LR) injection
Amount: 125
Unit: mL
Labor Progress
Created By: C Langley, RN Tue | 16:32
ActiveLaborOnset: Mon22:00
Fetal Assessment
BaseLine(bpm): 136 MonitorMode: External
Variability: Moderate
Accelerations: Present Decelerations: Absent
Uterine Activity
Frequency: 4min MonitorMode: External
Duration: 60sec Intensity: Strong
Vaginal Assessment
CervicalDilation: 6cm Effacement: 100%
Station: 0 Position: -
Pain Assessment
Created By: A Nicolau Tue | 16:34
Patient Charting Summary: Pain Assessment Tue 16:34
Chart Time: Tue|16:34
Pain Assessment
Do You Have Pain Now?
l Yes
Intensity of Pain
l 3
Care Plans
Priority

-- Medical Diagnosis: Pregnancy, term
Nursing Diagnosis:Risk for disturbed maternal/fetal dyad
Created By: A Nicolau Tue | 16:40
Type: Potential
Related To
Complications of pregnancy
Evidenced By
Late prenatal care
Expected Outcome Measurement/Time Frame Comments
Patient will cope with the discomforts of a high-risk pregnancy.
Intervention Rationale Comments
Care Plans
Priority

-- Medical Diagnosis: Pregnancy, term
Nursing Diagnosis:Risk for disturbed maternal/fetal dyad
Modified By: A Nicolau Tue | 17:15
Type: Potential
Related To
Evidenced By
ADDED-No prenatal care
Expected Outcome Measurement/Time Frame Comments
Intervention Rationale Comments
Care Plans
Priority

-- Medical Diagnosis: Pregnancy, term
Nursing Diagnosis:Risk for disturbed maternal/fetal dyad
Modified By: A Nicolau Tue | 17:15
Type: Potential
Related To
ADDED-Inadequate prenatal care
ADDED-Inadequate maternal nutrition
Evidenced By
ADDED-No prenatal care
Expected Outcome Measurement/Time Frame Comments
Intervention Rationale Comments
Care Plans
Priority

-- Medical Diagnosis: Pregnancy, term
Nursing Diagnosis:Risk for disturbed maternal/fetal dyad
Modified By: A Nicolau Tue | 17:15
Type: Potential
Related To
ADDED-Inadequate prenatal care
ADDED-Inadequate maternal nutrition
Evidenced By
ADDED-No prenatal care
ADDED-Body weight above ideal
Expected Outcome Measurement/Time Frame Comments
ADDED-Patient will verbalize understanding of individual risk factors prior to delivery of baby
Intervention Rationale Comments
Care Plans
Priority

-- Medical Diagnosis: Pregnancy, term
Nursing Diagnosis:Risk for disturbed maternal/fetal dyad
Modified By: A Nicolau Tue | 17:15
Type: Potential
Related To
ADDED-Inadequate prenatal care
ADDED-Inadequate maternal nutrition
Evidenced By
ADDED-No prenatal care
ADDED-Body weight above ideal
ADDED-Low nutrient meal selection
Expected Outcome Measurement/Time Frame Comments
Patient will cope with the discomforts of a high-risk pregnancy. until delivery of baby
ADDED-Patient will verbalize understanding of individual risk factors prior to delivery of baby
ADDED-Patient will verbalize understanding of fetal risk factors prior to delivery of baby
Intervention Rationale Comments
ADDED-Assess dietary intake using 24-hr recall Information about recent
intake identifies potential
deficits in dietary
requirements of increased
protein, iron, and calories
due to inappropriate food
choices of pregnant
adolescents (Doenges,
Moorhouse,& Murr, p. 4, 9,
2010, CD-ROM).
ADDED-Assess for potential risks to fetus Infants born to adolescent
mothers are at risk for
prematurity, low-birth weight,
birth trauma, and resultant
sequelae of mental
retardation, cerebral palsy,
and epilepsy (Doenges,
Moorhouse,& Murr, p. 9,
2010, CD-ROM).
ADDED-Review results of diagnostic/screening studies:
Hgb and Hct, STD screen
Determine oxygen-carrying
capacity and potential iron
defficiency; STD screen
identify treatment needs for
any positive cultures
(Doenges, Moorhouse,&
Murr, p. 11, 2010, CD-ROM).
ADDED-Weigh client and determine pregravid weight Weight gain during
pregnancy is calculated
according to normal growth
demands and pre-pregnancy
weight. Food idiosyncrasies,
which are related to
developmental stage and no
prenatal care contribute to
poor/inadequate intake,
resulting in fetal intrauterine
growth restrictions and low-
birth weight, and maternal
complications such as
pregnancy-induced
hypertension and associated
uterine ischemia (Doenges,
Moorhouse,& Murr, p. 4,
2010, CD-ROM)
Quiz Questions List
Question Expected
Answer
Student Answer Evaluation
What are the possible complications of epidural a
nalgesia during labor?
Hypotension, prol
onged labor, urina
ry retention, force
ps- or vacuum-ass
isted delivery
Hypotension, prol
onged labor, urina
ry retention, force
ps- or vacuum-ass
isted delivery

What collaborative interventions are commonly us
ed in an effort to prevent complications from epidu
ral administration?
Administering a fl
uid bolus prior to
administration
Administering a fl
uid bolus prior to
administration

You notice that Kevin stands back when you enter
the room and doesnt answer any questions. An a
ppropriate initial intervention would include:
Asking Kevin and
Emily to describe
their preferences f
or participation in
the birthing proce
ss
Asking Kevin and
Emily to describe
their preferences f
or participation in
the birthing proce
ss


Phase 2 Tue 17:25STUDENT EXCEEDED PHASE TIME
Student Charting
Pain Assessment
Created By: A Nicolau Tue | 17:29
Patient Charting Summary: Pain Assessment Tue 17:29
Chart Time: Tue|17:29
Pain Assessment
Do You Have Pain Now?
l Yes
Location of Pain
l Pressure like pain causing discomfort
Frequency of Pain
l Constant
Intensity of Pain
l 2
More information of Quality of Pain: l Per Pt. she is experiencing "a lot of pressure, not really pain"
Miscellaneous Nursing Notes
Created By: A Nicolau Tue | 18:20
Patient Charting Summary: Miscellaneous Nursing Notes Tue 18:20
Chart Time: Tue|18:20
Miscellaneous Nursing Notes
Miscellaneous Nursing Notes
l 1716: (Strip #1) FETAL MONITORING- FHR Baseline at 150 bpm, with minimal variability, and absence of both accelerations a
nd decelerations. UTERINE ACTIVITY- Contractions occurring every 4 min and 20 sec, lasting 70-80 sec, with intensity of contra
ctions between 55-65 mmHg and a resting tone of 10 mmHg.
1724: (Strip #2) FETAL MONITORING- Initial FHR Baseline at 150 bpm, with minmal variability, absence of accelerations, prese
nce of deceleration, and a FHR decreased to 108 bpm, indicative of moderate fetal bradycardia. Deceleration is variable (occur
ring in between contractions) and prolonged (lasting 2 min 40 sec > 2 min and deceleration is more then 15 bpm, unable to deter
mine if FHR returns to baseline within 10 min).UTERINE ACTIVITY- Contractions now 4 min apart, lasting 70 sec, intensity of 5
0 mmHg, and an unchanged resting to at 10 mmHg. Possible cause of variable decelerations accompanied by drop in FHR is c
ompression of umbilical cord which results in a lack of oxygen in fetal blood and a change in pt. position can alleviate these effec
ts.
Quiz Questions List
Question Expected
Answer
Student Answer Evaluation
What is the best way to describe the tracing? Fetal bradycardia Fetal deceleration
Emily asks you why she still feels discomfort in th
e pelvis saying I thought I wouldnt feel anything!
Didnt the epidural work? The best response is:
Epidural anesthe
sia blocks the pai
n pathways of the
uterine contraction
s, but does not tak
e away feelings of
pressure as the b
aby moves down i
n the pelvis. Lets t
ry a different positi
on.
Epidural anesthe
sia blocks the pai
n pathways of the
uterine contraction
s, but does not tak
e away feelings of
pressure as the b
aby moves down i
n the pelvis. Lets t
ry a different positi
on.

Which of the following would be the best set of int
erventions in the best order?
Change maternal
position, start oxy
gen, increase IV r
Change maternal
position, start oxy
gen, increase IV r

ate, call for help ate, call for help
What was the most likely cause of the event? Maternal hypotens
ion
Cord compressio
n


Phase 3 Tue 18:25STUDENT EXCEEDED PHASE TIME
Student Charting
System Nursing Interventions
Created By: A Nicolau Tue | 18:53
Patient Charting Summary: System Nursing Interventions Tue 18:53
Chart Time: Tue|18:53
Labor Interventions Missing vital signs for mom -9; missing fetal assessment and UC component -9
Labor Care
l Side-lying position
l Position changed
l Hydration by intravenous fluids
Patient Response
l Blood pressure maintained within expected parameters
l Maintain adequate hydration
Labor Care Notes
l Increased IV infusion rate - administered 500 mL fluid bolus to increase intravascular volume which caused an increase in blood
pressure
Postpartum Interventions
Postpartum Care
l No care required at this time
Neurological Interventions
Neurological Care
l No care required at this time
Cardiovascular/Peripheral Vascular Interventions
Cardiovascular/Peripheral Vascular Care
l No care required at this time
Respiratory Interventions
Respiratory Care
l Oxygen in use
l Continuous pulse oximetry
Patient Response
l Oxygen saturation improving
Respiratory Care Notes
l Pt placed on oxygen therapy via face mask at 10 L/min.
Musculoskeletal Interventions
Musculoskeletal Care
l No care required at this time
Gastrointestinal Interventions
Gastrointestinal Care
l No care required at this time
Genitourinary Interventions
Genitourinary Care
l No care required at this time
Integumentary Interventions
Integumentary Care
l No care required at this time
Pain Interventions; missing discussion with family re causes of fetal bradycardia -1
Pain Care
l No care required at this time
Quiz Questions List
Question Expected
Answer
Student Answer Evaluation
If the fetal heart rate had not responded to the abo
ve actions, what would have been the next priority
intervention?
Notify the provider Notify the provider
Which fetal heart rate tracing would NOT be indica
tive of a problem requiring intervention?
Early deceleration
s
Early deceleration
s


Phase 4 Tue 19:30
Student Charting
Quiz Questions List
Question Expected
Answer
Student Answer Evaluation
You notice that Emily has not voided in 3 hours. Y
ou know you should:
Assess the motor
function of Emilys
legs, offering the b
edpan if affected
by the epidural.
Use a straight cat
heter to empty Em
ilys bladder as thi
s is the priority an
d ambulating is no
t possible with an
epidural.

Emily expresses concern over what happened an
d wonders if it had an effect on her baby. What wo
The incident corr
ected quickly and
The incident corr
ected quickly and


Copyright 2014 Elsevier Inc. All Rights Reserved.
uld be the most appropriate response? the babys heart r
ate tracing is bett
er now, which is al
l reassuring.
the babys heart r
ate tracing is bett
er now, which is al
l reassuring.
Admission History
Home Medication Information
Information Received From: Self
Overall Grading:
Grade: 51%
Remarks: -19 Phase 3 -28 Phase 4 missing -2 missing 1 intervention and 1 rationale