Nrsg370 Evidence Based Nursing Research Assessment Answer

Candace Evans, a 42 year old woman is admitted to the operating theater for an elective lower uterine caesarian section (LUCS) under spinal anesthesia. At 38 weeks of pregnancy, Evans has been diagnosed with Placenta Previa. This is Miss Candace second pregnancy and she has not presented any of the previous problems exhibited during her first pregnancy where she experienced gestational diabetes. However, depression and anxiety were realized following the second birth. Although the second birth was uneventful, it was estimated that the patient experienced intraoperative blood loss at 150ml (Swetha, 2016). Most worryingly, it is realized that the patient’s vaginal pad had soaked blood with clots in it. Also, the patient’s partner seems anxious and worried to see the patient.

The diagnosis of placenta previa implies that the infant’s placenta had covered the patient’s cervix either partially or totally. As such, this was the main cause for the patient’s excessive bleeding resulting in the loss of an estimated 150ml of blood. The most probable risk factors for this condition in this case were the caesarian delivery and the age of the patient. If the patient doesn’t receive prompt care and monitoring, more blood could be lost and if the bleeding persists, the patient might require blood transfusion and intravenous fluids. The elective C-section was critical in preventing complications for the infant as well as the mother (Cho, 2014). Although the baby had safely been delivered, this condition severely threatened the health of the mother if immediate care was not provided to the mother.  The patient in this case probably suffered from postpartum hemorrhage (Fan et al, 2017). In this case the bleeding associated with the placenta previa occurred after the placenta was extracted and as such, the bleeding started after the delivery.

Identification of Nursing Problems

The patient exhibited excessive bleeding that was brought about by placenta previa which presented a significant threat to the health of the mother. This condition is the most common cause of bleeding especially during the third trimester of pregnancy. Hence, given the 38 week gestation, it can be noted that the bleeding arose from some factors such as over-sized placenta, endometrial lesions of uterine body or placental abnormality (Sato et al, 2015). Similarly, other studies have also indicated that the main causes of this condition emanates from an adhesive placenta and antenatal bleeding.

Although maternal mortality has significantly reduced over the years, studies have indicated that antenatal and post natal bleeding are the major current causes of maternal mortality. In relation the patient, it can be noted that the placenta previa resulted in massive hemorrhage which could also be subject to the successive caesarian delivery. Also, the bleeding from the placenta previa can be associated with the placental adhesion which subsequently exacerbated the postpartum hemorrhage thereby subjecting the patient to dangerous health problems that can be fatal (Kok et al, 2013).

Another problem arising from this case was psychological state of the patient since the patient exhibited anxiety and depression. Ideally, pregnant women or mothers diagnosed with placenta previa are in most cases emotionally unstable and are usually unaware of the expectations during the treatment process (Scott & Holleran, 2013). Moreover, they are in a state in which they cannot be able to judge their conditions accurately thereby necessitating more care and help from the nurses.

The primary mode of action to take would be to employ a feed forward control nursing model. This mode of treatment aims to examine, monitor and report on the patient’s vitals in order to form a basis for the best action to take in order to stop the bleeding. Alternatively, since the bleeding most likely occurred after the delivery, focus should be put on predicting the time that the bleeding should start (Zhu et al, 2013). Unlike antenatal bleeding associated with placenta previa, the time of postnatal bleeding is predictable since placental adhesion can easily be determined during pregnancy. Also, the psychological well-being of the patient needs to be prioritized given that the patient could be traumatized by her condition since she is not fully aware of the causes of excessive bleeding.

Discussion of the Nursing Care for the Patient

Feed forward control nursing model is critical in the provision of care for the patient and ultimately ensuring that the bleeding has been managed thereby putting the patient out of danger. This model ideally sets forth practical measures that improve the patient care provided by nurses. Precisely, this model comprises of patient examination, body positioning, monitoring vaginal bleeding and reporting, medical observation and psychological consultation (Zhu et al, 2013). In this mode of treatment, the patient should be encouraged to rest on their beds so as to allow for improvement of blood circulation in the placenta. In such a case, nurses should recommend lateral positioning for purposes of reducing umbilical cord compression or to prevent the inferior vena cava from being compressed by the uterine (Walker et al, 2013). Body examination and, monitoring and recording vaginal bleeding time is also essential.

Nurses should strive to explain the prognosis of the condition to the patient in order to enable them understand the cause of their excessive bleeding as well as reduce the anxiety (Cho, 2014). The blood volume of the patient should be checked in order to establish whether there is need to undertake blood transfusion. Notably, monitoring and reporting should enable nurses to sustain the patient’s normal blood volume as well as establish grounds for performing blood transfusion.

Focus can also be put on determining the time of bleeding and most importantly prepare the blood, fluids and man power to prevent the bleeding complications. As evidence reveal, previous C-section deliveries can be taken as key indicators for bleeding complications during successive deliveries. Likewise, postpartum blood loss are usually higher in the second planned caesarian section deliveries due to placenta adhesion (Hasegawa et al, 2012). The preparation of blood, fluids and manpower is also crucial especial when there is needed to perform high sensitive surgeries such as emergency hysterectomy. The need for such a procedure may arise as a result of excessive loss of blood after surgical procedures or uterine rupture (Radnia et al, 2017). Although the risks associated with this type of surgery are relatively high, it may be necessitated in order to save the life of the patient and in such cases, success rates of these surgeries have often been determined by the preparedness of nurses, physicians as well as midwives (Kollmann et al, 2016). Hence, it is the initial bleeding prediction that can facilitate nurses’ prompt decision making skills that can save the lives of patients such as Miss Candace.

Psychological counseling should also be performed in order to understand the patient’s emotional state. This counseling is in relation the patient’s nervousness, anxiety or depression that is exhibited by the patient as well as the patient’s partner (Kamara et al, 2013). Given the patient’s emotional state in relation the diagnosed conditions, nurses should strive to explain to the patients their conditions in a bid to calm them and enable them feel more comfortable.

Evaluation of Nursing Care Strategies

The aforementioned strategies are focused on improving the patient’s well-being by specifically reducing the risk of maternal morbidity and catering for the emotional status of the patient. The forward control nursing model enhances the level of services that nurses provide to patients and subsequently improves the patient satisfaction towards the clinical practice. This is mainly so because the patient is allowed more comfort, allocated continuous care dictated by the patient’s own needs and is provided with a favorable environment that speeds up the recovery process. Also psychological counseling ensured that the patient’s expected outcomes coincided with the treatment plans that were set in place (Scott & Holleran, 2013).

The encounter with this patient shades light on the importance of nurses in providing first-line care to patients. In such cases, the ability of nurses to make prompt decisions is critical towards reducing childbirth complications and most worryingly maternal deaths. Undertaking the above mentioned set of action plans could prove to be the key towards utilizing evidence based practices in clinical work. Consequently, the applications of such practices improves nurses’ problem solving skills and their expertise in resolving some of the most challenging situations in their work domain (Fan et al, 2017). Additionally, the applied clinical practice can enable nurses to understand the need for developing patient centered care that is specifically tailored to meet the needs of patients who they tend to.

Conclusion

For a patient diagnosed with placenta previa in her third trimester of pregnancy, nurses need to look out for the possible causes of the excessive bleeding which is most likely to arise from postpartum hemorrhage. In such cases, the nursing goals need to focus on reducing the risk of maternal bleeding and ensuring that the patient is in her rights state of mind to understand her condition. To achieve such objectives, nurses need to conduct a feed-forward control nursing model, attempt to predict the time of bleeding and undertake psychological counseling.

References

Cho, H. (2014). The Risk Factors for Antenatal Bleeding in Pregnancy with Placenta Previa, Journal of Pregnancy and Child Health, 4(6). Retrieved from https://www.omicsonline.org/open-access/the-risk-factors-for-antenatal-bleeding-in-pregnancy-with-placenta-previa-2376-127X-1000362-97235.html

Fan, D., Xia, Q., Liu, L., Wu, S., Tian, G., Wang, W., & Liu, Z. (2017). The Incidence of Postpartum Hemorrhage in Pregnant Women with Placenta Previa: A Systematic Review and Meta-Analysis. PLoS One, 12(1). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5249070/ 

Hasegawa, J., Nakamura, M., Hamada, S., & Okai, T. (2012). Prediction of Hemorrhage in Placenta Previa. Taiwanese Journal of Obstetrics and Gynecology, 51(1), 3-6. Retrieved from https://www.sciencedirect.com/science/article/pii/S1028455912000034 

Kamara, M., Henderson, J. J., Doherty, D. A., & Pennell, C. E. (2013). The Risk of Placenta Accreta Following Primary Elective Caesarean Delivery: A Case Control Study. An International Journal of Obstetrics and Gynecology, 120(7), 879-886. Retrieved from https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.12148 

Kollmann, M., Gaulhofer, J., Lang, U., & Klaritsch, P. (2016). Placenta Praevia: Incidence, Risk Factors and Outcome. The Journal of Maternal-Fetal & Neonatal Medicine, 29(9), 1395-1398. Retrieved from https://www.tandfonline.com/doi/abs/10.3109/14767058.2015.1049152?data-src=recsys&journalCode=ijmf20

Kok, N., Ruiter, L., Hof, M., Ravelli, A., Mol, B. W., Pajkrt, E., & Kazemier, B. (2013). Risk of Maternal and Neonatal Complications in Subsequent Pregnancy after Planned Caesarean Section in a First Birth, Compared with Emergency Caesarian Section: A Nationwide Comparative Study. An International Journal of Obstetrics and Gynecology, 121(2), 216-223. Retrieved from https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.12483 

Radnia, N., Nahid, M., Sharan, A., Shirmohamadi, S., & Otogara, M. (2017). Frequency and Causes of Emergency Hysterectomy along with Vaginal Delivery and Caesarian Section in Hamadan, Iran. Electronic Physician, 9(6), 4643-4647l. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5557147/ 

Sato, E., Nakayama, K., Nakamura, K., Ishikawa, M., & Kyo, S. (2015). A Case of Life-Threatening Uterine Bleeding due to Postmenopausal Uterine Arteriovenous Malformation. BMC Women’s Health, 15(10). Retrieved from https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-015-0163-8 

Scott, G. M., & Holleran, D. (2013). Expect the Unexpected During Pregnancy. Journal of Obstetrics, Gynecology and Neonatal Nursing, 42(1). Retrieved from https://onlinelibrary.wiley.com/doi/full/10.1111/1552-6909.12191

Swetha, B. (2016). Study on Association of Placenta Previa with Previous Cesarean Section Pregnancy. Journal of Dental and Medical Sciences, 15(5), 60-63. Retrieved from https://www.iosrjournals.org/iosr-jdms/papers/Vol15-Issue%205/Version-4/O1505046063.pdf 

Walker, M. G., Allen, L., Windrim, R. C., Kachura, J., & Kingdom, J. C. (2013). Multidisciplinary Management of Invasive Placenta Previa. Journal of Obstetrics and Gynecology Canada, 35(5), 417-425. Retrieved from https://www.jogc.com/article/S1701-2163(15)30932-4/fulltext

Zhu, Y., Zhang, S., Shan, W., & Hu, M. (2013). Feed-Forward Control Nursing Model in Expectant Treatment of Placenta Previa. Iranian Journal of Public Health. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5402776/