NURS 6552 Interactive Case Study Discussion Paper

NURS 6552 Interactive Case Study Discussion Paper

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Interactive Case Study
Background

Gloria Smart is a 55-year-old female who presents to your office today for regular gyn care. You read her medical history and note she received a cardiac stent at age 50, has mild hypertension, and is on Zocor, Plavix, and lisinopril. Surgical history is remarkable for tonsils as a child and bunion surgery. She works full time, by choice, because it “makes me feel young.” She is up to date with colonoscopies. Gyn history normal pap history, last DXA within normal limits, normal mammogram. BMI is 26. First menses age 14 and menopause age 52. She works out at her local gym 5 days a week. Social history is negative for tobacco and recreational drugs. She has an occasional glass of wine. She has never married and has been with her current partner for 2 years and will be getting married in 2 months. She has never been pregnant, and her partner has never had a child. NURS 6552 Interactive Case Study Discussion Paper

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Decision Point One

Gloria relates as you start to talk to her that she and her fiancé have been talking about it, and they would like to have a child. She wants a referral and some guidance.

What anticipatory guidance should you consider?
She is too old and should focus on maintaining her health and refer her for counseling.
Her medical history doesnâ€t show any contraindications to IVF.
X-She has some things in her history that she needs to consider.
She should have her fiancé checked before she does anything. NURS 6552 Interactive Case Study Discussion Paper
CORRECT
First, she has a significant cardiac history and is at high risk for cardiovascular complications. Additionally, Zocor and lisinopril are both category x drugs, and it is unknown whether Plavix is safe in pregnancy.
Decision Point Two

You discuss with Gloria about the issues with her medical problems and the issues with her current medications. You recommend that she set up an appointment with a maternal-fetal medicine specialist to discuss this and make recommendations for them.

Are there any other preconceptual recommendations you would make for her (or another woman considering pregnancy)?
X-Begin folic acid 400 mcg to 800 mcg daily. Discuss risks of alcohol and pregnancy.
Encourage her to interview infertility groups to help with IVF.
Make sure she has her mammogram and DXA scan before proceeding.
CORRECT
All women should consider preconceptual folic acid supplementation to help prevent neural tube defects. Gloria speaks with the maternal-fetal medicine specialist, who then speaks with her cardiologist. She is taken off her cholesterol meds, has her blood pressure meds changed to Procardia, stops the Plavix, and starts a baby aspirin daily. Her cardiac stress test is good, and her kidney function is reported as normal.
Decision Point Three NURS 6552 Interactive Case Study Discussion Paper

Gloria then sees an infertility specialist and discusses IVF and donor egg. She and her fiancé proceed and she gets pregnant on her second cycle. She is referred back to you at 12 weeks to be co-managed with the maternal-fetal medicine specialist.

What specific issues do you need to think about?
a. Diet changes; as a senior citizen, she needs more calcium than other women.
X-Baseline CMP and 24-hour urine.
Start discussing what things sheâ€ll need closer to delivery, and review how often sheâ€ll be seen.
CORRECT
As she has chronic hypertension and known cardiac disease, she is at a higher risk for preeclampsia. You need to see what her normal is at the beginning. NURS 6552 Interactive Case Study Discussion Paper
Decision Point Four

Gloria and her fiancé present to your office with a complaint that her blood pressure has been up at home when they check it with their BP cuff. Her fiancé thinks it might be related to a pain she has in her ribs on the right side that started after they went out Chinese food. They also ask if you can give her something to help with her “swelling” as her face wonâ€t look good at the planned marriage in 2 weeks. Her BP is 160/ 92, with a repeat 160/ 88. You note that she has 2+ pitting edema in her legs and that her face appears slightly swollen.

What is your next consideration?
Informing the patient and her fiancé that they just need to adjust her BP meds and the upper quadrant pain is probably related to her gallbladder.
Explain to the patient and fiancé that swelling is a common finding and is usually related to too much salt intake.
X-Explain to the patient and family the concerns for her high blood pressure and need for immediate treatment to prevent stroke and/or placental abruption. NURS 6552 Interactive Case Study Discussion Paper
CORRECT
Extreme hypertension is related to strokes in women and complication from preeclampsia/hypertension in pregnancy/HELLP is the second leading cause of death of women worldwide.

Her LFTs are quadruple normal and her platelets are 50,000. She is started on IV magnesium sulfate and given several doses of IV labetalol to get her blood pressure under control. Unfortunately, she abrupted late that day and delivered a male infant who lived about 20 minutes. After a rough course, including anuria and difficulty maintaining her pressures, she was eventually discharged home on Day 11.

JUST FOR THOUGHT
What would you do in this situation? Is it right to dismiss her desire, or should you facilitate it? How do you see your role here as an Advanced Practice Nurse? What ethical dilemmas and/or other issues do you need to consider? NURS 6552 Interactive Case Study Discussion Paper

Ethical issues
Psychological issues
Physical issues
Financial issues

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Review the interactive case studies in this weekâ€s Learning Resources. Select one of the cases to prepare your discussion post. Your post should address the following:
1.Summary of your chosen case study
2.What is your differential diagnosis?
3.Why did you make this diagnosis decision?
4.What is your treatment plan?
5.What evidence-based research can you provide to support your decision (choice for differential diagnosis and plan/intervention)?
6.What resources did you use to meet your best practice guidelines?
7.Address the ethical dilemmas and/or other issues for your case study:
Ethical issues
Psychological issues
Physical issues
Financial issues

NURS 6552 Interactive Case Study Discussion Paper