Acute Care Nursing - Reflections on Practice - Essay Example

Acute Care Nursing: Reflections on Practice: Midwifery Case B 1.0. Introduction The obstetrics specialty has tremendously advanced over time to include scientific improvements in general medicine, the capacity to measure blood pressure, and technical advancements in safe blood transfusion. These advancements have also incorporated inclusion of women’s role in the society through the examination of their reproductive destinies[Gre12]. Additionally, the progression in the practice of nurse-midwifery roles has evolved to include publication of standards that regulate conventional approach midwifery education and curriculum[Ave05]. This paper evaluates management of a midwifery case of a 29-year old who after presenting bleeding at 35.5 weeks of pregnancy undergoes an emergency caesarean section (C/S) and in the recovery room for post-surgery, bleeding continues despite IV infusion. After four hours, the woman is pale and responds poorly to non-verbal cues. 2.0. Midwifery management of the case The midwife has to assess Yee to ensure that her bleeding is not due to any other underlying risk factor but for cesarean section in her third stage of labor[Jac12]. Yee has experienced postpartum hemorrhage even though her blood loss after the cesarean birth is 700mL just four hours after the operation and there is a possibility of retained placenta fragments in her uterus given that her fundus is boggy and non-contracted[Yog04]. For accurate assessment of the fundus, the mother should be required to empty her bladder to eliminate interference with the uterine and lie flat on her back while flexing her knees. If the fundus is still soft and boggy, massaging should be performed gently until it gets firm. Retained fragments are ranked as one of the main cause of late postpartum hemorrhage and in the case of Yee, shock, continued bleeding, and boggy uterus are some main signs and symptoms. Further, the midwife must also ensure that fundus palpitation is done frequently to determine ongoing muscle tone but this should not involve over massage as it fatigues the muscles[BLy06]. Since effective uterine contraction is the goal, bladder distention must be prevented since it displaces the uterus. Besides the administration of intravenous fluid, a physician can provide manual removal especially if the cause is incomplete separations of the placenta. The midwife must use communication to manage Yee’s feelings of faintness and dizziness that makes her not to respond to verbal cues[Con10]. Sub-consciousness is due to orthostatic hypotension after birth and cautions the midwife of the patient’s safety. Hypotension arises from blood results loss causing blood pressure to lower to about 90/50 and a heart rate of 120 in attempts to circulate the blood in the body. Additionally, Yee is shocked as evident in her excessive anxiety, as a first time mother overwhelmed by fear of losing her first child and the fact that she has no prior experience in child delivery. For Yee, the hemorrhage experience is traumatic and so is her husband. The midwife has to offer considerable support to Yee and her family until she recovers emotionally and physically. Later debriefings would be beneficial and include discussions on issues about subsequent pregnancies and include other relevant health care professionals[Kli98]. Yee’s baby is in the special care unit and placed in headbox oxygen. This means that no mother-baby contact will be possible and bonding of the mother to the baby has to be delayed till the child is stable. Meanwhile, the midwife should provide a photograph of the baby to the mother and provide sufficient progress reports regarding the baby. Additionally, the midwife must reassure the mother that the about the condition of the baby before she is stable and can be assisted to visit her baby regularly. The midwife must also ensure that Yee remains warm to avoid hypothermia due to hypovolemic shock. Minimizing patient’s anxiety will include the midwife informing the obstetric member who then debriefs Yee and talks to her about the possibility of birth options with next pregnancy. Yee will also be provided with full explanations of all procedures and cares including lactation establishment and appropriate mother-craft education. The midwife must maintain constant monitoring and investigations through one-on-one care. Yee needs intensive monitoring based on the assessment outcome after delivery in the high-dependency unit. Since the patient is observed four hours after the surgery, her temperature should be taken and if found higher than 380C, the midwife should encourage Yee to take oral fluids to increase her hydration. This will serve well in reducing the temperature to a normal reading of 370C. The midwife should then document these findings and keep constant check after every four hours until she is stable. All documented entries must contain date and time, and printed name of patient and first signature as this will provide useful trends on physical parameters that will facilitate effective management. The inspection reveals Yee as moderately hypotensive and an immense fluid resuscitation has to be delayed despite the presence of dehydration but involving frequent administration of water and other fluids orally in bits[Gut04]. The delay is crucial given the association of intense resuscitation to death in patients with moderate hypotension. Since Yee experiences continued postpartum Haemorrhage, treatment using IV Hartmann Solution 1000ml should be continued since her uterine remains atonic and no massage for the fundus had been provided earlier. Additionally, an injection of Ergometrin should be issued especially since Yee has no observed or documented contraindications. According to Gutierrez, et al [Gut04], the primary goal in managing hemorrhagic shock must be retained at ensuring that Yee’s bleeding stops and that her blood circulation volume is restored. Yee complains of abdominal pain and for best results, the midwife must ensure that she is relaxed. She also has to be placed such that her head is placed on a pillow and the arms are placed across her chest while lying supine. However, since the abdomen is tight and rigid, examining the internal structures becomes hard and calls for the attainment of adequate abdomen muscles relaxation. Examiner must observe the abdomen for observed symmetry, nutrition status, and visible masses. Lateral symmetry will involve observing from above and the side and any present masses suspected at this point can be later confirmed through palpitation. Another cause of change in abdomen muscle tone is intrabdominal irritative processes. Patient relaxation and positioning will involve having the patient continue lying supine with arms relaxed at the chest sides; assuring patient of no discomforts, and using the patient’s hand to exert pressure tentatively on her abdomen. Other forms of relaxation would include encouraging deep but slow breathing. This will be followed by distractive questions or discussion of patient’s history which would also require having the client flex her thighs and knees. If the muscle tightening or rigidity is due to voluntary tension, palpitation process involves the use of a stethoscope and if patient doesn’t associate the instrument with pain, the result includes not reacting by muscle guarding. However, if the muscle tone’s rigidity is due to peritoneal irritation, the reaction equates to that by manual palpitation. 3.0. The basis for the signs and symptoms From the case of Yee, the process of hemorrhagic shock due to blood loss has been identified to follow a given process. First, Yee loses blood due to virginal bleeding. This loss results to decreased intravascular volume that translates to reduction in venous return, minimized blood pressure, and reduced cardiac output. In order to compensate, the body responds by elevating the heart rate as a way of facilitating circulation of the low blood levels faster through compensatory circulation to maintain sufficient blood supply to vital organs[Ros08]. Consequently, lesser vital organs experience vasoconstriction to ensure that more blood flows to the vital organs. Finally, body changes occur resulting to increased respiration rate and a feeling of anxiety. Less blood to the uterus results to reduced uterine perfusion especially due to cold clammy skin. The continued loss of blood then causes the body to transfer body fluids in the interstitial spaces into intravascular spaces[Coh12] but this does not assist in raising the blood pressure in any way. On the contrary, blood pressure continues to lower while the reduced perfusion is also experienced in the brain, uterine, and renal organs. Increased blood loss results to renal failure that could facilitate maternal and fetal death. According to Pairmand [Pai101], the primary indicators of caesarean section include previous caesarean delivery, dystocia, breech presentation, maternal request, and non-reassuring fetal heart rate. In the case of Yee, the signs and symptoms that necessitated the caesarian section included the virginal bleeding for the first baby who is only 35.5 weeks into pregnancy yet this is way below the full term gestation of 37 weeks [Yua10]. In addition, Yee’s preexisting medical conditions included blood pressure of 90/50 mmHg, heart rate of 96 beats per minute and respiratory rate of 22. The low blood pressure indicates loss of blood or low blood level resulting to increased heart rate that is way beyond the normal of 72 beats per second. With continued postpartum hemorrhage, the Yee’s blood pressure remains while the pulse rate increases to 120. This decrease results from significant loss of blood and fluid from the body thereby increasing the pulse rate as the heart attempts to circulate the reduced blood and oxygen debt. Further, the decreased blood volume causes increased respiratory rate although the blood lost by Yee is only about 700mL which is lower than the alarming loss of about 2000mL in a day. 4.0. Tools used to assess the Client/Patient Equipment needed in patient assessment include postpartum hemorrhage tray containing sutures, intravenous tubing, blood transfusion set, syringe and needles, Foley catheter, four sponge forceps, gloves and uterine packing[Bri09]. This tool is used for intravenous cannulation where a cannula is positioned inside a vein to offer venous access. The two major purposes of the cannula are to sample blood and medication, chemotherapy, fluids, and parental nutrition administration[For11]. With this tool, the indwelling part is made of material such as polyurethane which is considered to cause less damage to the veins. In addition, a comparison to steel needle utilized as the indwelling indicates less sharp injury risk. According to Aziz [Azi09], the use of IV Cannula is highly associated with healthcare acquired infections (HAIs). HAIs are generally never present during patient admission to hospital and are only acquired while in hospital. The use of flexible indwelling implies that continued venous access is possible without the need to perform numerous venipuncture[Azi09]. This way, the IV cannula has minimal invasions and safer unlike using a needle during each procedure. However, peripheral venous access must be avoided on injured, burned, or infected extremity where possible since this could result to contraindications. Peripheral vein is viable in this case given that Yee’s case is an emergency situation and requires constant monitoring and care to ensure that no blistering and tissue necrosis occurs due to leakage. Further, Saade, et al [Saa10] reveals that short for patients like Yee who is in an almost hypovolemic condition, short-term transcutaneous catheters are recommended since they are applicable in utmost two weeks while the condition is swiftly resolvable. Bladder catheter is attached to the patient’s bladder with an urometer to assist in urine measurement. Uterine packing medical procedure is implemented in severe hemorrhage cases that involve gauze firmed in vagina to absorb the blood and put on pressure on uterine arteries. The impact is to slow or stop bleeding due to vaginal lacerations or uterine bleeding. In hemorrhage management, uterine packing should be employed on the placental site bleeding or atony with efficiency improved using chitosan-covered gauze[Sch13]. Uterine balloon is also a form of virginal tamponade inserted into the uterine cavity to occupy the entire space and while exerting pressure greater than the systemic arterial to stop the arterial pressure. The suture package material comprises of needles in form of paired eyes, blunt point, curved and straight keith and vicyl. The four sponge forceps assist the identification and compression of cervical lacerations on uterine edges during uterine rapture. In order to access the vagina or lacerations, three vaginal retractors are essential to exposing them. 5.0. Outline and critique interventions undertaken on best international evidence For bleeding patients after cesarean section, several steps are followed [Placeholder1]. i. The patient should have bedside ultrasound done to determine whether there is any evidence of blood or clots within the uterus while an intrauterine balloon catheter is used to collect blood. Laboratory results for hematocrit, fibrinogen and placenta are measured. ii. The patient should first have the uterus massaged to expel clots or retained placental fragments inside the uterus. This is the case especially if the uterus does not successfully contract as demonstrated by a boggy fundus, signs of shock, and a rise in uterine fundal height which could be due to clots formation in the uterine cavity. Manually, this could involve using a cupped palm on uterine fundus in order to feel the contraction state[Wor031]. The fundus massaging should be in circular motion until sufficient contraction is achieved. A container should then be placed close to the vulva to collect bloods which then estimated and recorded. The amount of blood lost and the level of consciousness of the patient should be continuously assessed and the specialized personnel notified to determine whether blood transfusion is required. iii. If bleeding is consistent, application of bimanual uterine compression should be introduced. Bimanual compression is crucial in cases where bleeding persists regardless of uterine massage, oxytocin/ergometrine management placenta expulsion. The procedure requires wearing sterile or clean gloves and introducing the right hand into the vagina in a clenched fist while the hand’s back is posteriorly directed. The uterus is then firmly squeezed between the other hands on the abdomen until there is no further bleeding. However, aortic compression is required for persistent bleeding. iv. Aortic compression should be offered for its temporizing benefit in postpartum hemorrhage management as one plans for resuscitation and treatment especially in controlling placenta percreta in caesarean section[AMe09]. v. IV infusion should include 20 IU in 1000mL with 60 drops/minute for the initial dose while continued doses should contain IV infusion 10 IU in 1000mL at 30 drops in 60 seconds. vi. Persistent heavy bleeding should involve the use of ergometrine especially if the postpartum bleeding involves no enclampsia, hypertension, and pre-enclampsia. Initially, ergometrine dose includes 0.2mg introduced slowly but in continued doses, heavy bleeding will require repeating 0.2mg after 15 minutes for persistent heavy bleeding. vii. The final stage involves evaluation of the tear and classifies the degree as small or first, fourth, second, and third degree. If there is no bleeding of the tear, the midwife should leave it open. However, if the tears are within third or fourth degree where the perineum is involved, it should be referred to an obstetrician in case of no one with suturing skills. viii. The woman should then be encouraged to empty the bladder in case of distention the makes it difficult to pass urine with the bladder catheterized. Catheterizing requires washing hands, disinfecting urethral area, and putting on gloves. In gloves, the labia is then spread, catheter inserted 4 cm, urine recorded and catheter removed[Bri09]. 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