Week 3 Critical Thinking-Part B

Do not change the format of this worksheet

Save your name to the document to receive credit and for easier verification.
Use your own words only.
Answer completely

1. Your patient has been in labor for 5 hours. Her blood pressure had been
stable, averaging 130/80 when assessed between contractions and the FHR
pattern consistently exhibited criteria of a reassuring pattern. A lumbar
epidural block was initiated. Shortly afterward during assessment of
maternal vital signs and FHR, your patient’s blood pressure decreased to
102/60 and the FHR pattern began to exhibit a decrease in rate and
variability. Provide a rationale and reference for each response.

a. State what your patient is experiencing. Support your answer and

explain the physiologic basis for what is happening.
My patient is likely experiencing a hypotensive episode resulting from epidural-
induced sympathetic blockade and aortocaval compression. In many women,
epidural anesthesia usually leads to a reduction of blood pressure. This is because
epidural anesthesia causes a sympathetic blockade, inhibiting the sympathetic
signals that normally constrict blood vessels and support venous return. Generally,
the autonomic nervous system, consisting of the sympathetic and parasympathetic
nervous systems, plays a critical role in modulating the cardiovascular system and
maintaining hemodynamic stability during pregnancy, labor, and delivery. Through
the sympathetic nervous system, the body is able to regulate systemic vascular
resistance, heart rate, and venous return in order to ensure adequate blood
pressure and organ perfusion. However, epidural anesthesia causes a sympathetic
blockade, inhibiting the sympathetic signals that normally constrict blood vessels
and support venous return. This results in vasodilation, decreased systemic vascular
resistance, and impaired venous return from the lower extremities and pelvis.
Additionally, with aortocaval compression during labor further worsening this
problem, venous pooling occurs leading to decreased cardiac preload and output,
ultimately manifesting as a drop in blood pressure.

b. Write a nursing diagnosis and related intervention that reflects what

is currently taking place with this patient.
The post appropriate nursing diagnosis is decreased cardiac output related to
autonomic nervous system blockade as evidenced by decrease in blood pressure
and FHR abnormalities. The related intervention would be for the nurse to initiate
left uterine displacement and place patient in Trendelenburg position to improve
venous return and cardiac preload.
c. What are your immediate nursing actions and why?
My immediate nursing actions would be to quickly ensure a patent airway is
maintained through proper head and neck positioning, assess the patient's vital
signs including apical heart rate, respiratory rate and effort, color, and oxygen
saturation levels to evaluate her ABCs. I would apply supplemental oxygen via nasal
cannula to improve oxygen delivery and tissue perfusion. I would then initiate
continuous electronic monitoring of the maternal vital signs and fetal heart rate to
assess the patient's hemodynamic status and the fetal response in real-time.
Concurrently, I would start an intravenous fluids bolus to rapidly restore
intravascular volume and improve preload to the heart. I would also promptly notify
the obstetric provider of the patient's conditionally unstable presentation in
preparation for possible medical interventions. The administration of Vasopressors
like ephedrine or phenylephrine may be warranted to treat persistent hypotension
and help improve hemodynamics and oxygen delivery to the fetus, whose heart rate
is seeing a decrease indicative of possible stress. These coordinated multifaceted
nursing and medical interventions aim to stabilize the mother and optimize fetal
status in this concerning clinical scenario.

2. Your other patient is a primigravida, who has elected for a continuous

epidural block as her pharmacologic method of choice during childbirth.
Provide a rationale and reference for each response.

a. Identify the assessment that should be used to determine her

readiness for the initiation of the epidural block.
The assessment that should be used to determine her readiness for the initiation of
the epidural block is the partogram to evaluate cervical dilation and effacement as
labor advances appropriately.
b. Describe the preparation methods that should be implemented and
why?
Preparation for the initiation of the continuous epidural block begins with providing
thorough education to the patient. I would take the time to fully inform her about
what to expect with the procedure itself, including placement of the catheter and
ongoing administration of anesthetic medications. An explanation of potential risks
such as hypotension, as well as anticipated benefits for pain management during
labor would help ensure her understanding and consent. Additionally, preparation
involves confirming her NPO status in order to minimize the risk of pulmonary
aspiration if intervention is needed. Taking a baseline set of vital signs and
reviewing the patient's health history aids in assessing her overall status and risk
factors. Finally, completing any necessary preoperative laboratory tests helps
optimize safety and allows medical risks to be identified and addressed
prophylactically. By fully instructing the patient and completing these pre-
procedure evaluations and preparations, we are able to mitigate complications and
optimize outcomes associated with her chosen method of epidural anesthesia for
labor and delivery.
c. Describe two positions you could help her assume for the induction of
the epidural block and why?
The two positions that could be used are sitting upright or leaving side with knees
flexed while maintaining the spine in a neutral straight position by supporting the
pregnant abdomen with pillows. These positions provide better access and comfort
during insertion.
 d. Outline the nursing care management interventions recommended
while this patient is receiving the anesthesia to ensure her well-being
and that of her fetus.
Nursing care includes continuous monitoring of maternal VS, FHR, urine output,
motor and sensory levels. Early ambulation with assistance to promote circulation
and prevent complications like hypotension. Maintaining hydration and assessing
for signs of local anesthetic toxicity are also important.