Name: Gallo, Irish Jane, Campo

Section/Group: BSN2A/GROUP2

Case Simulation 123

INSTRUCTIONS:

All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list
them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response
is not legible, it will be marked as? and you will need to rewrite it.

Scenario

You are working as the triage nurse in the emergency department at a busy tertiary care center. A woman comes in complaining of
very heavy vaginal bleeding and extreme pain. S.K. is single, 47 years of age, and as been bleeding for 24 hours, soaking a pad an
hour. She works in a law firm as a paralegal and was embarrassed yesterday when she leaked around her pad and stained a chair in the
conference room. She has two sexual partners currently and has been relying on condoms for birth control. She thinks her last
menstrual period was 2 months ago, but they have been irregular and she is not sure. She has had some occasional spotting during the
past 6 months. She states she is afraid of the amount of bleeding in the past 24 hours.

1. Identify three conditions that would require emergency care and could prove life threatening.

The severe bleeding could possibly be severe menorrhagia or it could be an ectopic pregnancy. If the bleeding continues,
S.K. could go into hypovolemic shock. If emergency care is not sought out and is left untreated, the ectopic pregnancy and
hypovolemic shock could be fatal.

2. She asks you, “Could I be pregnant?” How will you respond?

I would respond by asking her when was the last time she was sexually active and if protection was used. I would also let her
know that pregnancy could be a possibility but the pregnancy test will be done to know for sure.

3. You ask her how she would feel if she was pregnant, and she says, “It would ruin my life.” She states she is a single mother
with two children in junior high school. What can you tell her to help her with her obvious distress?

First is establishing rapport to our patient, to build trust between nurse and the patient.
Ask her why she feels it would ruin her life, in what aspect? – Allow her to express feelings.
Inform her of options available if she is pregnant- adoption, abortion, or outside resources that could help financially if she
decides to keep the baby.
Use supportive expressions to relieve their distress and always be positive in front of them and smile always. Imagine
ourselves in their situation to easily understand what they want to say and speak always gently and softly, talk in a way that
inspires hope and without touching or hugging( some are like it but other’s don’t)
Refer her to counselor to talk about her feelings

Respond to Distress Using NURSE TECHNIQUE

N- aming: “ I can see this is not what you expected to hear”
U-nderstanding: “I can only imagine how you may be feeling right now. Is there anything you want to talk about?”
R-especting: “You have shown a lot of courage through all this.”
S-upporting: I will be here with you through this.”
E-xploring: Tell me more about what is affecting you? Tell me more about what upsets/scares you the most”.

4. Describe the assessment you would need to perform to differentiate what might be occurring with S.K.

Assess the cause of abnormal bleeding or excessive bleeding and extreme pain.
Pelvic Exam
Blood test including a blood clotting profile, hormones test, Test for sexually transmitted diseases.
Pain Scale Assessment

Chart View

5. Interpret S.K.'s laboratory results and vital signs.

Laboratory Test Results

Hgb 12.2 g/dL
Hct 44%
RBC 4.2 dL
Vital Signs
Blood pressure 110/68 mm Hg
Heart rate 88 beats/min
Respiratory rate 22 breaths/min

The Laboratory results shows that Hgb 12.2 grams per deciliter (normal-12.0 to 15.5 grams per deciliter), Hct is 44% which is normal
(36.1% to 44.3 %), RBC 4.2 deciliter (normal) In vital signs, Blood Pressure 110/68 mmHg which is not normal because the normal
range would be less than 120 and less than 80 and the normal range of patient age in blood pressure would be 124 over 78.5 mmHg.
Heart rate 88 beats per minute normal because the normal adults ranges is 60 to 100 beats per minute. Respiratory Rate 22 breaths per
minute, it is not normal in adult at rest (12 to 20 breaths per minute)

CASE STUDY PROGRESS

You determine that S.K. is stable at the present level of bleeding; she is not diaphoretic or pale. The physician orders an ultrasound
(US) to determine whether she is pregnant and to evaluate some possible causes of her bleeding. During her US, her blood pressure
drops to 90/42 mm Hg, and she complains of considerable cramping.

CHART VIEW
Physician's Orders
Infuse 1 L of D5LR over 4 hours
Meperidine (Demerol) 25 mg IV now

6. Before administering the meperidine (Demerol), what will you ask her?

Before administering I would ask for any allergies, a pain assessment and what other medications is currently taking.

We need to know the medical history of the patient, especially if the patient has brain disorders (such as head injury, tumor,
seizures) breathing problems(asthma, sleep apnea, chronic obstructive pulmonary disease COPD), gallbladder, disease,
kidney disease, mental/ mood disorders and family history.

7. What precautions do you need to take while administering the meperidine (Demerol)?

Take meperidine exactly as directed. Do not take more of it and more often,
Before Taking Meperidine: Tell your doctor if you are allergic in meperidine, any other medications. You should know that
meperidine may take you drowsy. Do not drive a car or operate machinery until you know how this medication affects you.
This is more common that when you are first taking meperidine you are experiencing dizziness, lightheadedness, and fainting
when you get up too quickly from a lying position. To avoid this problem get out of bed slowly, resting your feet on the floor
for a few minutes before standing up.

8. You are preparing to infuse the D5LR. The available IV tubing supplies 15 gtt/mL. At how many gtts/min will you regulate
the infusion?

(1000ml x 15 gtt/min) / (4hrs X 60 min) = 32.60 > 33 gtt/min

CASE STUDY PROGRESS

Her US is negative for pregnancy; she does not have an ectopic or intrauterine pregnancy. The US shows a very thick endometrial
lining, even after 24 hours of bleeding.

9. S.K. is obviously relieved about not being pregnant, but she expresses fear that this could be cancer. What should you tell her to
reassure her?

I would let her know that the bleeding could be due to several reasons and not specifically cancer, and that the doctor didn’t not find
any suspicion of cancer in her ultrasound if he did he would be discussing option now. A test she could have done to rule out or
confirm cancer is a biopsy.

10. S.K. asks what she can do to keep this from happening again. Please respond.
Check and Monitor the monthly period (Regular or Irregular)
If the she is sexually active (don’t forget to used a contraceptive to avoid STD)

11. What risk factors will you ask her about before discussing birth control pills as a treatment option?

If she has a history of thrombophlebitis disease, liver disease, gallbladder disease, hypertension. Diabetes, migraines, hypercoagulable
disorders, hyperlipidemia, heavy smoking, or undiagnosed uterine bleeding.

12. If S.K. is prescribed birth control pills for the treatment of her bleeding problem, what other risks should she be aware of if she is
using the pills for birth control?

That birth control pills increased the risk of myocardial infarction, thromboembolic disorders( blood clots) and stroke.

CASE STUDY PROGRESS

S.K. is more comfortable now. The physician suggests birth control pills to control her bleeding. He tells her to take one pill, four
times a day for the next 5 days or until her bleeding stops. Once the bleeding has stopped, she should continue using the medication,
one pill/day, for the rest of the cycle. Because she will need to continue the pills for at least 3 months, she will need to follow up with
her OB/GYN.

13. What warning signs and symptoms do you want to tell her about as she starts her contraceptive pills?

Warning Signs to report are depression, breast lump, jaundice, several abdominal or leg pain, severe chest pain, or shortness of breath,
headaches or dizziness, eye vision loss or blurring, speech problems.

14. Which statements indicate that S.K. understands the discharge instructions? (Select all that apply.)
a. “I will call if I continue to have heavy bleeding, soaking a pad an hour.”
b. “I can take three hundred twenty-five milligrams of aspirin every six hours for the cramping pain.”
c. “If I get dizzy or feel my heart beating funny, I will come back to the ER.”
d. “I will avoid sexual intercourse until the bleeding has completely stopped.”
e. “I will try to eat more beans and spinach over the next several days.”