Patient Scenario, Chapter 20, Nursing Care of a Family Experiencing

a Pregnancy Complication from a Preexisting or Newly Acquired

Illness

A WOMAN WITH EARLY PREGNANCY CONCERNS

Paula Taylor is a 38-year-old, G1P0 seen during her 12th week of pregnancy. She
was diagnosed as having sickle-cell anemia as a child.

CHIEF CONCERN:
“I can’t sleep at night, I am so short of breath.”

HISTORY OF CHIEF CONCERN:

The client entered pregnancy without any feeling of shortness of breath. Since 2
weeks ago, she has been extremely fatigued, has mild constant swelling in her
ankles, a persistent cough, inability to walk upstairs without becoming breathless,
and orthopnea so severe at night she cannot sleep without four pillows.

FAMILY PROFILE:
The client is a massage therapist in boutique spa. Her boyfriend is a plumber. The
client states she has to continue working because her husband does not earn
enough to pay the mortgage on their house without her help. The main reason is,
though, she says, “I’ll go crazy without people to talk to. I’m a people person.” She
does not smoke and no alcohol ingestion since pregnant.

HISTORY OF PAST ILLNESSES:

She developed scoliosis as an early adolescent. She has retainer rods inserted to
support her spine.

HISTORY OF FAMILY ILLNESSES:

One aunt has breast cancer; an uncle has arteriosclerotic heart disease. Her sister
has recurrent absence seizures. A cousin has type 1 diabetes mellitus.

DAY HISTORY:

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 Nutrition: 24-hour recall:
Breakfast: 1 serving oatmeal with raisins; 1 glass orange juice; 1 cup coffee
Lunch: 1 tuna fish sandwich; 1 serving salad; 1 cup coffee
Dinner: 1 pork chop; 1 serving potatoes; 1 serving spinach; 1 cup coffee
Snacks: Eats ice cubes almost constantly to relieve heartburn; has a craving
to eat the “lead” in pencils
Sleep: Tries to sleep 8 hours a night but receives only 3 to 4 hours because of
constant waking with shortness of breath
Recreation: Enjoys talking to chat room on Web site

GYNECOLOGIC HISTORY:
Menarche was at 13 years; cycle duration: 30 days; flow duration: 6 days;
moderately heavy; mild dysmenorrhea. She became sexually active at age 16
years; she had therapy for gonorrhea shortly afterward. She has been using a
diaphragm and vaginal foam for 2 years of marriage.

OBSTETRIC HISTORY:
She had no previous pregnancies. Present pregnancy was not planned but is
wanted. The couple was planning on waiting 3 more months and then starting a
family.

REVIEW OF SYMPTOMS:
She has had three colds since beginning pregnancy; otherwise negative except for
symptoms of chief concern.

PHYSICAL EXAMINATION:
General appearance: Extremely worried and tired appearing pregnant female;
height: 5 ft 4 in.; weight 180 lb; BP: 135/88 mmHg
HEENT: Negative
Chest: Prominent grade 2 diastolic murmur heard at left sternal margin; apical first
heart sound is accentuated; second sound is split; cardiac enlargement
suggested by percussion; heart rate: 96 beats/min; rhonchi heard on lung
auscultation; respiratory rate: 22 breaths/min
Abdomen: Fundal height: 28 cm; linea nigra and striae present on abdomen; FHR:

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 158 beats/min
Pelvic: Deferred
Rectum: Two 1-cm hemorrhoids present; no bleeding
Extremities: Edema 2+ present on both legs extending from feet to mid-calf
Neurologic: Deep tendon reflexes 2+

LABORATORY RESULTS:
Hemoglobin: 9 gm/dl
Urinalysis: Negative for protein and glucose

Paula is diagnosed with iron-deficiency anemia and congestive heart failure. She is
prescribed digoxin and bed rest.

1. The cardiovascular disorders that most commonly casuedifficulty during

pregnancy are valve damage. What disease usually cause valve damage? 4 points

Valge damage caused by: Rheumatic fever or Kawasaki

Disease and congenital anomalies

2. Considering the patients with heart problems, you as a nurse explain how

pregnancy taxes the circulatory system. Explain how pregnancy taxes the

corcalatory systems of every woman? 2 points

Pregnancy taxes the circulatory system of every women

even those without cardiac disease, because both the blood
volume and cardiac output increases approximately 30%
during pregnancy

3. During Assessment to the cardioavascular system on a pregnant women,

murmurs are heard with auscultation, how are you going to explain to the women

why murmurs occur? Would it be considered abnormal? 2 points

Because of the increased blood flow past valves, functional

and transient murmurs can be heard in many women
during a usual preganancy.

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 4. The preganant woman verbalizes tehat she experience palpitations? How are you

going to explain this to the woman? Could this be a sign of a cardiovascular

disease? 2 points

Heart palpitations on sudden exertion are also usual So

theres no sign of cardiovascular disease because
palpitating is normal during pregnancy

5. The danger of pregnancy in a woman wit cardiac disease occurs primarily

because of the increase circulatory volume. When is the most dangerous time for a

woman with cardiovascular disease, what weeks of pregnancy? 2 points

The most dangerous time for her is in weeks 28 to 32 just

after the blood volume peaks.

6. As rule, a womane with functioning artificial heart valves, pacemaker implants

and woman with heart transplants are expected what pregnancy outcome? 3 points

Expected to have successful pregnancy

7. Heart disease classification is important determinant of preganancy outcome. A

pregnant woman with heart disease, slightly compromised, ordinary physical

activity causes excessive excessive fatigue, palpitation, and dyspnea or anginal

pain, falls on what class in classification of heart disease? 2 points

Classification II

8. A severely compromise patient, unable to carry out any physical activity withour

experiencing discomfort, even at rest symptoms of cardiac insufficiency or anginal

pain are present, falls what class? 2 points

Classification IV

9. To predict pregnancy outcomes, heart disease is divided into four categories.

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 What are the expected oucomes with each class? 5 points

Class I or II heart disease can expect to experience a

normal pregnancy and birth. And with class III can
complete pregnancy by maintaining special interventions
such as bed rest. And a women with class IV heart disease
are usually advised to avoid pregnancy because they are in
cardiac failure even at rest and when they are not
pregnant.

10. What is pulmonary edema? 2 points

Is when pressure in the pulmonary vein reaches a point of

about 25mmHg, fluid begins to pass from the pulmonary
capillary membranes into interstitial spaces surrounding
the lung alveoli and then into the alveoli themselves.
Pulmonary edema produces profound shortness of breath
as it interferes with oxygencarbon dioxide exchange.

11. As pulmonary edema becomes severe, a woman cannot sleep in any position,

except with her chest and head elevated, what term is reffered to when a woan

cannot sleep in any position except with cheast and head is elevated? How could

this helps? 4 points

Orthopnea as elevating her chest this way allows fluid to

settle to the bottom of her lungs and frees space for gas
exchange.

12. What is paroxysmal nocturnal dyspnea? Why does this occurs? 4 points

Paroxysmal nocturnal dyspnea suddenly waking at night

with shortness of breath. This occurs because heart action
is more effective when she is at rest
13. A woman with heart disease delivers a baby and notice her baby’s extremities

are turning blue? What term use to refer this? As a nurse how are you going to

explain this to the woman? 2 points

Blue baby syndrome, also known as infant

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 methemoglobinemia, is a condition where a baby's skin
turns blue. As a nurse explain to the women that infants of
women with svere heart disease tend to have a low birth
weights or be small for gestational age because of acidosis,
which develops due to poor oxygen/carbon dioxide
exchange or not being furnished with enough nutrients.

14. Iron Deficiency Anemia is the most common anemia during pregnancy, what

laboratories are done to detect this, and what specific levels of lab results are

indicative of IDA? 3 points

Many women enter pregnancy with defiency of iron

resulting from a combination of a diet low in iron, heavey
menstrual periods, or unwise weight reducing programs,
Iron Deficiency is confirmed by a corresponding low serum
iron level under 30 dl and an increased iron binding
capacity over 400 dl.

15. How is Iron defeincy prevented? And as a nurse, What dietary counseling should

a give to the woman? 2 points

Advise woman to take iron supplements with orange juice

or a vitamin C supplement, which supplies ascorbic
acid.they need to eat a diet high in iron green leafy
vegetables, meat and legumes. Also prescribed therapeutic
levels of medication (120 to 200 mg elemental iron per
day) usually in the form of ferrous sulfate or ferrous
gluconate.

16. How are women with IDA treated? 2 points

Iron supplements.

Diet. Diets that include the following foods can help treat
or prevent iron deficiency:
Treating the underlying cause of bleeding. Iron
supplements won't help if excess bleeding causes the
deficiency. A doctor may prescribe birth control pills to
women who have heavy periods.

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