Question

The patient is a 22-year-old G1P1 who delivered vaginally a healthy 7 lb 8 oz boy approximately 3 hours ago with a midline episiotomy. Fundus is above the umbilicus, lochia is moderate. She has an intravenous infusion with Pitocin 20 units in her right arm. The patient is complaining of an excruciating headache, blurred vision, and epigastric pain that radiates to the upper right quadrant of her abdomen. The patient is also complaining of perineal pain. Her deep tendon reflexes are brisk, and vital signs are: T. 38.2, HR 98, RR. 18, BP 169/102, SpO² = 92%

Physical examination of the patient’s abdomen reveals a boggy uterus, massage done with the expulsion of medium to large clots and small gushes of blood from the vagina. Her right labia is swollen and firm to touch. A retaining urinary catheter was placed with a urinary output measured in the last hour is 25 mL.

Stat laboratory blood was drawn and sent including complete blood count (CBC), liver function test (LFTs), and comprehensive metabolic panel (CMP). The lab results are:

1. CBC: White cell count = 9,000 x 10³; Hemoglobin = 9.2mg/dL; Hematocrit =27.6%; platelets = 8,000 x 10³

2. LFTs: Alanine Aminotransferase (ALT) = 379 IU/L; Aspartate Aminotransferase (AST) = 425 IU/L; Alkaline Phosphatase (ALP) = 380

3. Comprehensive Metabolic Panel: Na = 138 mEq/L; K = 4.9 mEq/L; Calcium = 8.5 mg/dL, carbon dioxide (CO2) = 21 mmol/L; chloride (Cl) = 103 mmol/L; albumin = 4.3 g/dL, total protein = 6.0 g/dL, bilirubin = 0.1m, BUN = 25 mg/dL, Creatinine = 0.6 mg/dL

Questions:

1. What are the nurse’s priorities for this patient?
2. What symptoms and signs should alert the nurse to potential problems that might need immediate intervention?
3. What would be the best way for the nurse to respond to the patient’s condition?
4. What might be the significance of the patient’s perineal pain?
5. Explain the significance of the patient’s laboratory CBC, and LFT results.
6. How would you measure the patient's blood loss?

Answer 1

#The nurse's priority for this patient should be

• To control the high blood pressure pressure in order to prevent eclampsia ,seizure
• Ensure administration of oxygen as this condition may risk the patient to hypoxia
• Reduce the body temperature to normal
• Assess the patient for complications of HELLP syndrome and take appropriate preventative measures
• Inform the obstetrician regarding patient status and start medical intervention immediately
• Assess the patient for abnormal discharge or bleeding as the platelets are very low
• Prepare the patient for administration of blood products as per the order

#The signs and symptoms which can alert the nurse to assess that a potential problems are in patient are as following

• Elevated blood pressure
• Boggy uterus can be a sign for uterine atony
• Elevated liver enzymes (HELLP syndrome in post partum period)
• Low haemoglobin ,hematocrit can indicate blood loss
• Low platelets making suspicion for bleeding risk
• Reduced urine output indicating acute renal failure
• Severe headache ,blurred vision ,abdominal pain (right upper quadrant (HELLP syndrome)

#The nurse should report to the concerned provider

Assess the patient's vital, neurological status ,postnatal complication

The perineal pain could be because of the episiotomy,high blood pressure leading to swollen right labia.

#The CBC and LFT results are

• Low haemoglobin ,Low platelets :anemia
• Low platelet :thrombocytopenia
• elevated ALT, AST ,increased protein indicates problem is associated to liver

#The patient blood loss can be calculated using the level of hemoglobin (or hematocrit levels )to blood volume after multiplying it.