Princess Levie Ceniza BSN 2A group 1

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.

Uncontrolled hemorrhage because of early pregnancy loss, excess endometrial tissue, exposed
fibroid tissue, or low hormone levels

Ectopic pregnancy with a ruptured fallopian tube

Miscarriage

Pelvic inflammatory disease

Cancerous lesion in the uterus

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

Yes. Explain that women in their forties may have an unplanned pregnancy because they think they
are too old to conceive and their irregular cycles mean they are no longer fertile. Because she still is
having cycles, though irregular, she is likely still able to conceive; and because she went 2 months
without a period, there is a possibility she is pregnant. You explain that if she is pregnant, there is a
higher incidence of miscarriage because the eggs are older and sometimes do not develop properly,
and the level of hormone in the luteal phase might be too low to sustain a pregnancy.
 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?

Her distress and concern can lead to prenatal depression. It is a condition in which women undergo depressive
characteristics under the influence of stress from the unborn child. I will educate her about her health condition
and other possibilities such as menopause for her condition. Since it is not sure that the patient is pregnant so I
will ask her to do not worry until the test result comes. Moreover, I will try to empower her by positive thoughts
about pregnancy. I will try to raise hope in her by informing her about the opportunities that can arise with her
unborn child.

4. Describe the assessment you would need to perform to differentiate what might be occurring with S.K.
Thoroughly assess her current complaint. Have her describe the length of time she has had
symptoms, any associated symptoms, and whether she ever experienced these symptoms before.
Obtain a complete menstrual, obstetric, sexual, and contraceptive history.
 Assess for signs of anemia and hypovolemia: Ask if she feels lightheaded, fatigued, short of breath,
or dizzy. Observe her general appearance, vital signs, and skin, noting the color and moisture.
Assess for the cause of the bleeding, noting any signs and symptoms of bleeding disorders,
including bruising and petechiae.
 Assess the abdomen for tenderness, rigidity, or masses. Auscultate bowel sounds.
Assist the provider with a gynecologic exam with Pap test, bimanual examination, and rectal
examination.
Additional information should be obtained regarding comorbidities and medications taken. Ask
about illnesses, changes in weight or nutritional intake, exercise, and drug ingestion.

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
S.K.'s Hgb and Hct levels are within normal limits; her RBC count is also within normal limits. Her BP,
heart rate, and respiratory rate are all within normal limits; she does not have the same presentation
as someone with hemorrhage with imminent hypovolemic shock.

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?
 Ask her whether she has ever had a reaction to this or similar drugs.

Ask her whether she is taking antidepressants, especially monoamine oxidase inhibitors (MAOIs).
Severe reactions, including death, have occurred in patients taking both meperidine and MAO
inhibitors.
Yes, the dose of 25 mg is safe because the safe range is 15-35 mg for adults.

Before administering I would ask for any allergies, a pain assessment, and what
other medications she is currently taking
 7. What precautions do you need to take while administering the meperidine (Demerol)?

Administer the dose over a minimum of 4 to 5 minutes

Have oxygen equipment and naloxone (Narcan) at her bedside
Monitor S.K.'s respiratory status every 15 minutes for 1 hour afterward
Intravenous (IV) meperidine has several side effects, so give it must be given slowly, over at least 4
to 5 minutes. Each 10 mg must be diluted in at least 1 mL of normal saline (NS), D5W, D5NS, or other
compatible infusion solution. IV administration is associated with the possibility of hypotension
and respiratory depression, so monitor vital signs accordingly. Because of the risk of respiratory
depression, have oxygen equipment and naloxone (Narcan) at her bedside. Keeping her supine will
decrease the risk of hypotension.

8. You are preparing to infuse the D5LR. The available IV tubing supplies 15 gtt/mL. At how many gtt/min will
you regulate the infusion?
62.5 or 63 gtt/min
1000/4 = 250 mL/hr
15 gtt × 250 mL/60 min = 62.5 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?
Endometrial cancer is the least likely cause of her bleeding. Her OB/GYN can perform a simple test
called an endometrial biopsy. This test is done by suctioning out a small sample of the endometrium
with a thin pipette (straw). The cells are sent to a pathologist to see whether they are normal,
whether they are changing in ways that could become cancer at some point, or whether actual
cancer cells are present. Suggest she have this test done soon for her peace of mind.

10. S.K. asks what she can do to keep this from happening again. Please respond.
The usual treatment for heavy, irregular bleeding in midlife is oral contraceptive pills at a low dose.
Estrogen at 20 to 25 mcg in combination with a progestin will stabilize and protect the uterine lining.
She needs to take the pills to control her bleeding and regulate her cycles to protect the lining of her
uterus and to protect against anemia from excess blood loss each month.

11. What risk factors will you ask her about before discussing birth control pills as a treatment
option?
Does she smoke? Smokers older than age 35 are encouraged not to use birth control methods
containing estrogen because of the increased risk of blood clots associated with estrogen.
Does she have a personal or family history of blood clots? Oral contraceptives increase the
incidence of deep vein thrombosis (DVT), pulmonary embolus (PE), and stroke if women smoke or
have a history of clots.
Has she ever had high BP, heart disease, liver disease, breast cancer or breast lumps, migraine
headaches with neurologic symptoms, diabetes mellitus (DM), or gallbladder disease? If she has
any of these problems, she might still be able to take low-dose contraceptives. The physician
would have to weigh the benefits versus the risks.

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 increase the risk for myocardial infarction, thromboembolic disorders (blood clots), and
a stroke.

CASE STUDY PROGRESSA

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, severe abdominal
or leg pain, severe chest pain or shortness of breath, headaches or dizziness, eye
vision loss or blurring, and 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.”

Discharge instructions after an episode of abnormal uterine bleeding include teaching the
patient to call the health care provider if she passes clots the size of a half-dollar or larger, soaks
a pad or tampon at least every hour, or develops severe abdominal pain. Ibuprofen or naproxen
can be taken for cramps or discomfort. Avoid aspirin products because they can increase bleeding.

Dizziness or heart palpitations can signal excessive blood loss, and the patient should contact the
health care practitioner right away. She can engage in sexual activity and other activities of daily
living, including swimming and exercise, while still bleeding. To combat anemia related to the blood
loss, she should try to get plenty of iron in her diet, eating foods such as liver, beans, and spinach.