Ms. X is a 34 year old female. The patient is a G3 P2, with both children delivered by C-section, with the only complication in both being low birth weights. Ms. X has a longstanding history of hypertension, anxiety and depression. Additional health history includes a vitamin D deficiency, back surgery in 05/06 due to a herniated disc, and two previous cesarean sections.
Ms. X delivered a healthy baby boy weighing 6 lb. 2 ounces, with apgar scores of 8 and 9; the patient did well through delivery and during the postoperative stage. No lack of sensation or motor function following discontinuation of epidural anesthesia was noted. The two previous infants delivered without extreme difficulty, with the first born via c-section d/t fetal distress. Throughout the procedure and throughout the recovery stage, the patient had the positive support of husband. The incision site was clean with steri-strips covering, but without any signs of infection (no redness, swelling, drainage, or edema noted).
The patient has no difficulties with breastfeeding, but a lack of nutrition was a possibility of great concern. The two previous infants were breast-fed by the patient, without any difficulty. Ms. X was hesitant towards talking about food in general, and was seen to only eat 25% – 50% of the small amounts of food ordered.
Patient’s Name: X
Date of Admission: 02/04/15
Date of Patient Care: 02/11/15
Hypertension, anxiety, depression
Pathophysiology #1 Anxiety Disorder
Anxiety disorder refers to a group of conditions in which affected clients experience persistent anxiety that they cannot dismiss. Coping mechanisms are ineffective, and anxiety interferes with activities of daily living. People with anxiety disorders feel that the core of their personalities is being threatened, even when no actual danger exists. They perceive a threat, even if it is not present in reality. Anxiety can be mild, moderate, or severe, affecting cogni- tive, psychological, and physical function accordingly. Anxiety disorders affect approximately 40 million Americans 18 years or older in any given year (Kessler et al., 2008). They are the most common psychiatric disorders for adults and children. PhD, Wanda M., RN, FAAN. Psychiatric Mental Health Nursing: Evidence-Based Concepts, Skills, and Practices. Lippincott Williams & Wilkins, 10/2012. VitalBook file.
Most anxiety disorders result from a combination of neurobiologic vulnerabilities, developmental stage, and psychosocial stress. This disorder associated with hyperactivity in limbic regions of the brain, particularly the amygdala. Higher cortical executive areas are unable to normalize the limbic response to stimuli the symptoms of anxiety disorders occur as the result of an imbalance in the emotional centers of the brain. These cognitive centers are in the frontal lobe and include the prefrontal frontal cortex (PFC), which is responsible for executive functions of the brain such as decision making and planning, moderating, and understanding social behavior. The orbitofrontal cortex (OFC) is responsible for coding information, controlling impulses, and regulating mood. The hippocampus is responsible for processing threatening stimuli and is thought to play a role in anxiety disorders by encoding this information into memories.
The research suggests that individuals exposed to traumatic events may use their dorsal executive network to process emotional/affective issues and, as a result, dimin- ish their executive control. Additional biologic factors that may contribute to the onset of anxiety disorders include physical illness; exposure to substances such as cocaine, amphetamines, cannabis, and caffeine; and exposure to physical or psychological danger, trauma, or both. Research examining the link between brain chemistry and specific environmental or psychosocial stresses regard-ing anxiety disorders is ongoing. Wanda M., RN, FAAN. Psychiatric Mental Health Nursing: Evidence-Based Concepts, Skills, and Practices. Lippincott Williams & Wilkins, 10/2012. VitalBook file.
Pathophysiology #2 Hypertension
Two or more elevated blood pressure measurements (systolic greater than or equal to 140 mm Hg or diastolic greater than or equal to 90 mm Hg) at two or more visits (see Classifying hypertension) Usually begins as benign disease, slowly progressing to accelerated or malignant state Two major types: essential hypertension (also called primary or idiopathic hypertension ) and secondary hypertension, which results from renal disease or another identifiable cause Severe, fulminant form, called malignant hypertension, that commonly arises from both types and is a medical emergency
Several theories attempt to explain the pathophysiology of hypertension: Changes in arteriolar bed cause increased peripheral vascular resistance. Abnormally increased tone in the sympathetic nervous system originates in the vasomotor system centers, causing increased peripheral vascular resistance. Increased blood volume results from renal or hormonal dysfunction. Increase in arteriolar thickening is caused by genetic factors, leading to increased peripheral vascular resistance. Abnormal renin release results in the formation of angiotensin II, which constricts the arterioles and increases blood volume. (Taylor, Carol R. Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Wolters Kluwer Health, 11/2010. VitalBook file.Pathophysiology)
Ineffective coping related to surgery evidenced by client’s verbalized fear
Ineffective self Health Management related to hypertension
Fatigue related to demands of caring for newborn while recovering from childbirth
1. Provide safe calm environment
2. Encourage patient to talk about feelings and concerns.
3. Teach relaxation techniques (deep breathing exercise, meditation, progressive muscle relaxation)
4. Assess client for severe depression or thoughts about death or suicide
5. Ask client how she usually copes with similar stressors in her life.
1.Verbalize an increased understanding of proper health care maintenance.
2. Identifying poor health behaviors
3. Identify actions that are detrimental to health and demonstrate intention to change behavior.
4. Have an increased understanding of proper health care maintenance.
5. Assess social support and include family and friends/ or significant others in teaching about condition and care
1. Asses patient rest and activity patterns
2. Assist by identifying the primary cause of fatigue (worry, lack of sleep at night etc.)
3. Assess patient for postpartum complications: signs of infection, fever. Redness, edema
4. Assess client for postpartum blues. Discuss hormonal changes, role changes and exhaustion as precipitation factors
5. Assess patient’s diet and encourage patient to ingest recommended amounts of calories, protein, vitamin C, and fluids
When people are fearful, being heard in the atmosphere of calm helps foster a scene of connectedness and gain control over what will happen.
When concerns are stated out loud, problems can be discussed and feelings of isolation decreased
When patients learn to lower levels of anxiety their ability to assess a situation and utilize their own problem solving skills are improved
Clients who are severe depressed or talking about death/suiside need immediate psychiatric help
Asking patient to identify and evaluate usual coping mechanisms increases client self-awareness
Even though self-management is the ideal approach to client care, studies show significant discrepancies between provider’s and client’s views.
Research shows that self-efficacy is associated with significant improvements in self-management behaviors.
Research shows that self-management education improves the outcome of chronic illness.
Self-management education help to achieve positive health outcomes such as reduction in systolic blood pressure
Patient will need good social support for lifestyle changes needed after the baby is born
Assessment provides information about adequacy of client rest and activity pattern.
Patient may be too tired to identify primary problem without some assistance
Excessive bleeding may cause anemia and fatigue related to insufficient hemoglobin. Signs of infection also include fatigue
A short-lived peiod of depression accompanied by emotional fragility is common in the first few weeks postpartum. Continued depression needs further investigation
Poor nutrition and dehydration add to feeling fatigue. Protein and vitamin C are needed for tissue regeneration after childbirth
Identify current stresses leading to ineffective coping
Explore personal strengths and plan new ways to cope with stresses
Verbalize an increased understanding of proper health care maintenance.
Identifying poor health behaviors
Identify actions that are detrimental to health and demonstrate intention to change behavior.
Have an increased understanding of proper health care maintenance.
Patient will experience less fatigue
Patient will be able to identify priority activities that she will focus on during postpartum period
Patient and family members will identify tasks that family members will be responsible for.