Rapid Assessment of a Client (2)

Professor and class,

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Scenario: You are in the process of admitting Ashley, a 27-year-old who is 28 weeks pregnant with her first child, to the obstetric unit for complaints of a headache, dizziness, and swelling of her lower extremities when she suddenly begins seizing.

While admitting Ashley to the Obstetric Unit she begins to seize my first response would be to place her in a lateral decubitus position to maintain her airway and lower the bed to the lowest setting to make sure she will not fall out of bed while in the midst of the seizure. Checking her surroundings to ensure that she will not further injure herself with anything that is sharp or hard that may fall on her and have the patient care tech (PCT) obtain padded side rails for increased safety. I would check the time so that I could assess the duration of the seizure from start to finish and notify the Obstetrician on call. As described by Jarvis (2016), a seizure is a time-limited event caused by excessive, hypersynchronous discharge of neurons in the brain that can be caused by a multitude of reasons. Once the seizure had stopped I would establish respiratory support immediately after the seizure with supplemental oxygen, assess her vital signs paying close attention to her blood pressure and need for treatment while placing her on a continuous pulse oximetry. I would also place her on a fetal heart monitor and obtain a fetal ultrasound as well to check the status of the fetus and its Manning score (www.ncbi.nlm.nih.gov). With the symptoms, she is presenting with a headache, dizziness, swelling of her lower extremities, and now with a new-onset seizure, I can determine she was being admitted for monitoring and treatment of possible pre-eclampsia that has potentially escalated to life-threatening eclampsia. I would obtain an order to start her on a continuous IV infusion of “Magnesium sulfate (6 g IV load over 20 minutes, then continuous infusion of 2 g/hour)” (Smith, N. C., & Caple, C. M. 2018). Watching her for signs & symptoms of a potential toxicity ie: visual changes, somnolence, flushing, muscle paralysis, loss of patellar reflexes or pulmonary edema (www.ncbi.nlm.nih.gov).

Situation: Ashley is a 27-year-old female who at 28 weeks gestation with her first pregnancy had which we believe to be her first tonic/clonic seizure lasting approximately 3 minutes.

Background: Ashley is a 27-year-old female who is 28 weeks pregnant presented to the hospital with complaints of a headache, dizziness, and swelling of her lower extremities for evaluation and while being admitted had a witnessed tonic-clonic seizure. No information was obtained prior to the seizure of any previous complications with her pregnancy and history of prenatal care. She is now in the post-ictal state and remains stable.

Assessment: Continue to monitor the patient’s status, maintain a patent airway, pulse oximetry, oxygen supplementation and obtain ABG values, administer Sodium Bicarb if PH (<7.1) warrants to correct acidosis. Place her on a cardiac monitor and continue to assess vital signs and treat hypertension as indicated with antihypertensives and monitor urinary output and increased swelling of the legs. Monitor for reoccurring seizures and maintain protocols to prevent seizure-related injury and aspiration. Maintain Magnesium Sulfate continuous infusion as ordered while monitoring treatment effectiveness. Closely monitor serum magnesium levels, respiratory rate, reflexes, and urine output to avoid magnesium toxicity and prevent cardiac arrest. Administer calcium gluconate 1 g IV to counteract magnesium toxicity if required. Continue monitoring fetal heart tones and potential fetal complications of eclampsia which includes a deceleration of fetal heart tones, placental abruption, asphyxia, uteroplacental insufficiency, and preterm birth (Smith, N. C., & Caple, C. M. 2018).

Recommendation: I would provide education to the patient for the short-term treatment goals we have set related to her current condition and preventative measures we are taking to decrease her risk of further seizures from occurring. This would include maintaining her infusion of magnesium sulfate, continued reduction in her blood pressure and further monitoring of her oxygen levels. Once stable I would prepare her for delivery within 24 hours by explaining that this is the only cure for eclampsia during pregnancy is to deliver the baby and placenta. Obtaining an order for the administration of Corticosteroids to improve fetal lung maturity before delivery would be beneficial. (Smith, N. C., & Caple, C. M. 2018).

Reference

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC27991…

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC31484…

Jarvis, C. (2016). Physical examination & health assessment (7th ed.). Philadelphia, PA: Saunders.

Smith, N. C., & Caple, C. M. (2018). Eclampsia. CINAHL Nursing Guide,

Kim