NU 661 Discussion 1: Advocating for Patient Care

Sample Answer for NU 661 Discussion 1: Advocating for Patient Care Included After Question

Initial Post

Create and post a 3–5-minute video response to this physician and advocate for a different plan of care for your patient. Prepare your video as if you were actually speaking to the physician, including using professional language and professional attire.

In your video be sure to include your specific plan of care (testing, medications, and so on). If you agree with the physician regarding bedrest, give supporting evidence. If not, then support your plan.

In your post, in addition to the video, attach a Word document that outlines your plan of care for that patient and includes a list of APA-formatted references to support your plan of care for your patient. Post your video and reference list no later than Day 3.

A Sample Answer For the Assignment: NU 661 Discussion 1: Advocating for Patient Care

Title: NU 661 Discussion 1: Advocating for Patient Care

For this patient, bedrest is not something that is needed. Studies actually show that there is no evidence that bedrest will decrease chances of Preterm birth (Robinson & Norwitz, 2020). Bedrest can lead to an increased risk of developing thromboembolic events, negative psychosocial effects, and can lead to deconditioning (Robinson & Norwitz, 2020). The patient has a long and closed cervix. She has a history of delivering at 32 and 34 weeks, and therefore requires some testing to be done before she is sent home.

First, she should undergo fetal fibronectin (fFN) testing, as this is a useful biochemical marker for predicting preterm birth (Jordan et al., 2019). A positive result would mean she is likely to deliver in the 1-2weeks and should be monitored more closely (Jordan et al., 2019). If she has had a healthy pregnancy to this point, she may be a candidate for progesterone therapy. Progesterone has several actions: suppresses myometrial activity, contractile genes, reduces biophysical response to oxytocin, suppresses cytokines and prostaglandins, and prevents the formation of gap junctions (Jordan et al., 2019).

An intramuscular dose of 250mg of Makena would be appropriate given her history of spontaneous preterm births (Jordan et al., 2019). Progesterone is useful in cases where a woman is not in acute preterm labor, which this woman is not because she is not dilated (Lockwood, 2020). Causes of contractions should be explored by drawing a CBC and CMP to check iron levels and electrolytes. She may require a few fluid boluses during her hospital stay or iron supplementation.

References


Jordan, R. G., Farley, C. L., & Grace, K. T. (2019). Prenatal and postnatal care: A woman-centered approach. (2nd ed.). Wiley.


Lockwood, C. (2020, June 12). Preterm labor: Clinical findings, diagnostic evaluation, and initial treatment. UpToDate.

 
Robinson, J. N., & Norwitz, E. R. (2020, Sept. 22). Preterm birth: Risk factors, interventions for risk reduction, and maternal prognosis. UpToDate.

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A Sample Answer 2 For the Assignment: NU 661 Discussion 1: Advocating for Patient Care

Title: NU 661 Discussion 1: Advocating for Patient Care

According to Jordan et al. (2019), preterm labor is classified as occurring after 20 weeks of gestation and prior to 37 weeks’ gestation. In the United States, about 12% of births occur before and 50% of those births are preceded by preterm labor (Kilpatrick, 2012). Preterm labor can occur through multiple different biophysical pathways that include premature activation of the maternal or fetal hypothalamus pituitary adrenal axis, exaggerated inflammatory response, and decidual membrane activation (Jordan et al., 2019).

There are also many complications for the neonate who is born premature. Complications include respiratory distress syndrome, hypoglycemia, jaundice, anemia, cerebral palsy, and cognitive or developmental delays (Jordan et al., 20219).  Ms. Divine Pearl is a G5P2 and has a history of preterm labor. Her two previous pregnancies were preterm at 32 and 34 weeks. She is currently pregnant at 28 weeks’ gestation and presents complaining of regular painful contractions that have been ongoing for the last 2 hours.

The doctor observes that her cervix is long and closed. He writes orders for bedrest for the remainder of her hospital stay and following discharge. At 28 weeks, she is considered very preterm (Jordan et al., 2019). While I understand the doctor’s choice of bedrest given this patients history, I respectfully disagree with his decision of strict bedrest. Further evaluation is necessary before the decision of bedrest is made.

First, we will consult with doctor to assess whether he has a done a fern test to confirm the presence of amniotic fluid and a fetal fibronectin test. Fibronectin is a glycoprotein found in high concentrations in the amniotic fluid and its presence in the cervical vaginal secretion after 20 weeks’ gestation is abnormal (Jordan et al., 2019). A positive test would indicate the risk of preterm birth occurring within 1-2 weeks (Crowley, n.d., 06:15). Prior to doing the fetal fibronectin you must assess whether the patient has not had sexual intercourse within 24 hours as this could result in a false positive (Crowley, n.d, 06:20).

Since the doctor has already done a manual exam of the cervix and determined that it is closed and long, we can use an ultrasound to confirm that the length is approximately 4.0cm (Crowley, n.d, 05:00). Following the ultrasound, we can also conduct a non-stress test to assess how the fetus is doing. Since she Ms. Pearl is having regular painful contractions, we will place the tocomonitor and assess for uterine irritability or contractions (Crowley, n.d, 04:15). It is important to remember that contractions alone do not equate to preterm labor (Crowley, n.d, 07:23). Ms. Devine should then be assessed for dehydration as this can cause uterine irritability. If she is dehydrated, we would start her on lactated ringers with an initial bolus followed by a liter at 125ml/hr (Crowley, n.d, 05:32).

With her history of preterm births and the contractions she is a good candidate for progestins such as 17-alpha-hydroxyprogesterone caproate. It is a weekly IM injection of 250mg (Crowley, n.d, 13:00). Another option for Ms. Pearl is a calcium channel blocker such as nifedipine (Crowley, n.d, 11:13) which can help stop contractions in preterm labor. Moving forward, Ms. Pearl should avoid excessive activity and high impact aerobics as it draws away blood supply from uterus and can cause uterine irritability.

Teach the patient stress reduction techniques such as deep breathing or guided imagery. Another activity to avoid is breast stimulation or intercourse. Sperm has prostaglandins which can initiate labor contractions. Lastly, bed rest has not been shown to be effective for the prevention of preterm labor (Medley et al, 2018) and carries the risk of the mother developing a DVT or PE (Crowley, n.d, 04:19). However, an alternative to bedrest orders could include home uterine monitoring.  There are options for Ms. Pearl once a full assessment is complete.

References:

Crowley, K. (n.d). Assessment and Diagnostics. [Video]. Regis College. https://myonline.regiscollege.edu/mod/page/view.php?id=481105&forceview=1

Crowley, K. (n.d). Education and Prevention. [Video]. Regis College. https://myonline.regiscollege.edu/mod/page/view.php?id=481105&forceview=1

Crowley, K. (n.d). Management and Treatment of Preterm Labor. [Video]. Regis College. https://myonline.regiscollege.edu/mod/page/view.php?id=481105&forceview=1

Jordan, R. G., Farley, C. L., & Grace, K. T. (2018). Prenatal and Postnatal Care: A Woman-Centered Approach (2nd Edition). Wiley Global Research (STMS). https://bookshelf.vitalsource.com/books/9781119318361

Kilpatrick, S. J. (2012). Management of preterm labor: Have we learned anything since 2003? Contemporary OB/GYN57(9), 54–55.

Medley, N., Vogel, J. P., Care, A., Alfirevic, Z., & Medley, N. (n.d.). Interventions during pregnancy to prevent preterm birth: an overview of Cochrane systematic reviews. Cochrane Database of Systematic Reviews, 11