Case Presentation Help

[CollaborateRN]

I have to present the following case study. I made a Powerpoint Presentation with all the answers. I just wanted to know if any experienced L&D nurses had any input to offer regarding this case study besides "do your own homework." Thank you in advance!

Scenario:

T.N. Delivered a healthy male infant 2 hours ago. She had a midline episiotomy. This is her sixth pregnancy. She is para 4014. (Para indicates past history and does not list this delivery until later.) She had an epidural block for her labor and delivery. She is now admitted to the postpartum unit.

1. What is important to note in the initial assessment?

I used the acronym BUBBLE-HE

2. You find a boggy fundus during your assessment. What corrective measures can be instituted?

Uterine atony: Fundal massage, monitor vitals, check for full bladder, IV oxytocin, encourage breastfeeding, and monitor output

3. The patient complains of pain and discomfort in her perineal area. How should you respond?

Ice packs, positioning, donut cushion, sitz bath, local/PO analgesia

4. What patient teaching is vital for the nurse to do after delivery?

Teaching regarding reportable signs, fundal massage, infection-prevention, perineal care, hygienic practices, safety, bonding, breast-care, breast-feeding, etc

5. T.N. tells you that she must go back to work in 6 weeks and isn't sure she can continue breast feeding. What options are available to her?

Suggest pumping, breast-feeding schedule, refer to breast-feeding coordinator

Case Study Progress

T.N. believes the AM and PM breast feeding schedule will work for her once she returns to work.

We will be graded on the following basis:

*** Presentation teams must email the instructor a brief bibliography or reference list on the topic one week before the presentation. ***

1. Present the case study and examine the role of critical thinking in the clinical decision making process.
   
2. Analyze the case study using the principles of Roy Adaptation Theory or Paterson & Zderad Humanistic Science Theory in guiding the patient care.
   
3. Incorporate source of standards and guidelines for the care of patient with such a diagnosis. Include those of professional and institutional organizations and accrediting bodies such as the Nursing Code of Ethics, ANA Standards of Practice, JACHO standards, agency policies and procedures. Also specify the relevant standards employed to the specific case study be presented.
   
4. Examine the case study questions with the class. Clarify, add to, and/or correct responses as appropriate.
   
5. Based on data collected, identify assumptions in the case study, add missing data as appropriate. Indicate evidence of biases, specific values, legal and ethical issues, and the importance of significant others participation in patient care.
   
6. Demonstrate effective use of audio visuals.

I am having trouble with points 2 and 3 and 5 in the grading criteria. I will highly appreciate any input with regard to those points.

[koffeehoLic_RN]

im not an experienced L&D nurse but i have an input for #2

Sister Callista Roy's Adaptation Theory consists of four main concepts: person, health, environment, and nursing. The person is defined here as an open, adaptive system who uses coping skills to deal with stressors. The goal of nursing is the promotion of the adaptive responses in relation to the four adaptive modes. It involves a six-step nursing process which includes:

1.) assessment of behaviour

2.) assessment of stimuli

3.) nursing diagnosis

4.) goal setting

5.) intervention and

6.) evaluation.

In the first step, the person's behaviour in each of the four modes is observed. This behaviour is then compared with norms and is deemed either adaptive or ineffective.

The second step is concerned with factors that influence behaviour. Stimuli are classified as focal, contextual or residual (Rambo, 1984).

The nursing diagnosis (third step) is the statement of the ineffective behaviours along with the identification of the probable cause.

In the fourth step, goal setting is the focus. Goals need to be realistic and attainable and are set in collaboration with the person (Andrews & Roy, 1991).

Intervention occurs as the fifth step, and this is when the stimuli are manipulated. It is also called the 'doing phase' (Rambo).

In the final stage, evaluation takes place. The degree of change as evidenced by change in behaviour, is determined. Ineffective behaviours would be reassessed, and the interventions would be revised (Andrews & Roy).

Now, as for your answer in #2, you should relate it to the steps as stated above. Take note of your assessment for the pt's behaviour and the stimuli. Make a nursing diagnosis for that situation. Set your attainable goals. Intervene and evaluate the outcomes.

[CEG]

I don't know what the "am and pm nursing schedule" is. You may want to clarify that unless it is a commonly used term where you are.

I don't know if they discuss the reason in depth somewhere but you could discuss the fact that routine episiotomy is not recommended by any organization and is not evidence-based if that is the case here for #3 (try ACOGs recomendations on that).

[CollaborateRN]

Thank you.

I am not sure what the am and pm schedule is either. I am trying to find literature that explains the concept. Case progress is included in the question part of the case study. So, I really don't know what the author's meant by that. I'm guessing it's some kind of a feeding schedule analogous to a toileting schedule.

Thanks for the tip about the episiotomy. That is useful information!

[NurseNora, BSN, RN]

For pain and discomfort in the perineal area, be sure to look carefully (turn patient to the side and have her bend the knee of the top leg so you get a good look at her perineum) and touch with a gloved finger. She may be developing a hematoma which is more likely after an episiotomy. S/S of hematoma are more than the usual pain, unrelieved by usual pain medication, swelling (sometimes you can see it, sometimes not), firmness to the touch, rectal pressure (if it's in the posterior lady partsl wall and pressing on the rectum).

I never advise the use of a donut pillow. Sitting on a firm surface is usually better. Picture it: when you sit on a soft surface, or on a donut, you sink down and actually pull on the episiotomy. If you sit on a firm surface, you don't sink down and there is no traction on the episiotomy; if anything, it kinda pushes it together.

As far as the points you will be graded on, I'm so glad I'm no longer in nursing school and have to think about applying someone's nursing theories to my care plan. It is necessary to help you learn, but I've been out of nursing school longer than you've been alive and I just don't think like that anymore. Good luck.

[NurseNora, BSN, RN]

AWHONN (Association of Women's Health, Obstetrics, and Neonatal Nurses) is our professional organization and sets most of our standards. I believe one of the threads at the top of this section discusses some of the AWHONN standards.

ACOG (American College of Obstetricians and Gynecologists) also sets standards, but they are geared to the MD. AWHONN and ACOG agree on most standards; they do try to work in coordination with each other--sorta.

[babyktchr, BSN, RN]

I am thinking the AM/PM schedule for breastfeeding refers to moms who will breastfeed in the morning before work, supplement with formula or pumped breast milk during the day and then will breastfeed when they get home in the evening.

I, too, and glad I am not in nursing school anymore. All of this seems so overwhelming. Seems like a lot of work for one patient, doesn't it? Good luck to you.

[NurseNora, BSN, RN]

Don't know if you need any teaching resources, but my two favorite sites for free downloadable breastfeeding information, available in both English and Spanish, are the Mass. Breastfeeding Coalition and the Los Angles Breastfeeding Task Force. I especially like the second one because their handouts are very basic and reader friendly. The sites are:

massbfc.org and breastfeedingtaskforla.org

[CollaborateRN]

Thank you for the responses fellow nurses. It's stressful to work full-time + study full-time simultaneously. Some days, it's tough to find a couple hours to sleep. It's also tough to do a perfect job when one is stretched out so thin, but I try to give it my 100%. I want to thank you all for the input. It definitely helps.

I have made a Powerpoint Presentation based on the case study. Now, I have to spruce it up based on the grading criteria. Needs a lot more work!