Karen 30 y/o G1 P0 is 32 weeks gestation. She developed preeclampsia at 28 weeks and has been home on modified bed rest. A home health nurse visits her twice a week and calls her daily.
The home health nurse makes a home visit. Karen tells her “I have a terrible headache and hardly slept last night. I took Tylenol and got no relief.” The nurse asks about other symptoms, Karen replies, ” My vision is blurry, I’m seeing spots and my stomach hurts.” Karen’s BP 154/100, she has pitting edema in her legs, and her first void tested 3+ for protein. The nurse calls the physician who decides to admit her to L&D immediately. At the hospital Karen continues to c/o severe headache with seeing spots. Physical assessment: BP 160/110, 4+ DTRs, 3 beats of ankle clonus. The electronic monitor reveals fetal heart rate 145 with minimal variability and periodic late decelerations, irritable uterine contractions.
- What is the primary concern or client need in this situation? Support answer with the data in the case. (10 points)
- List other client needs/problems in the case. (10 points)
- Identify any additional information or assessment data that is needed by the nurse in planning care for this client? (10 points)
- What nursing actions are appropriate? What is the priority nursing action? Describe other nursing interventions that are important to providing optimal care. (10 points)
- Describe the roles/responsibilities of the interprofessional health care team members who may be involved in providing care. (10 Points)
