QuestionKindly answer the evidence based nursing (EBN)with the given case study as a reference. Atta

QuestionKindly answer the evidence based nursing (EBN)with the given case study as a reference. Attached is the format of EBN.OB CASE STUDY:My patient Madam Suzanna 29years old gravida 4 para 2+1 electively admitted at 32 weeks of period of amenorrhea for expectant management of twin pregnancy with asymptomatic placenta previa type II posterior.Currently patient is well and has no complain of pervaginal bleeding and fetal movement was good. She has no signs of labour like contraction, leaking liquor or passing show. Her blood pressure was stable and there was no complain of headache, blurred vission or fits. There is also no lethargy or pallor.Her last normal menstrual period is on 10/8/10 and her estimated date of delivery is on 17/5/11. Currently she is at 35 weeks and 2 days of period of amenorrhea.She has a background history of secondary subfertility for 7 years. She also has failed intrauterine insemination and intrauterine death in 2007.Antenatal history :It is a planned and wanted pregnancy. Urinary pregnancy test was done on 6th week of period of amenorrhea and the initial booking was done on 10th week period of amenorrhea. Dating scan was done on 7th week and it correspond to date. Placenta previa was detected when scan was done on 31 weeks period of amenorrhea.Antenatal screeningBlood pressure : 105/65Urine : no albumin detectedHemoglobin :12.9 g/dlWeight :71-90gHeight :161cmBlood Group :0 positiveVDRL/HIV/Hep B : negetiveMGTT(modified glucose tolerance test) done at 12 weeks of period of amenorrhea: 4.2/6.0(normal) and repeated on 32 weeks period of amenorrhea showed result 4.1/5.3(normal)Latest scan was on 23/3/11 with the result of twin 1 and 2 at 32 weeks and 2 days of period of amenorrhea. Twin 1 was on cephalic presentation and twin 2 on tranverse presentation. Twin 1 weighs 1894g and twin 2 weighs 1886g. It is a monochorionic and diamniotic twin. It has only one palcenta. Liquor was adequate and other parameters correspond to date.Past obstetric history:In 2004 she delivered a baby girl by full term sponteneous vaginal delivery. The babies weight is 3.3 kg. In 2003 she had complete miscarriage at 5 weeks of period of amenorrhea. In 2007 she had intrauterine death at 26 weeks of period of amenorrhea due to positive toxoplasmosis and cytomegalovirus positive. The babies weight was 980g.Past gynaecological history:She had a regular menstrual cycle. She attend age at 12 years old with a regular flow of 3 to 4 days every 1 month. She had no history of dysmenorrhea, menorrhagia, or intermenstrual bleeding. Last pap smear was done on 2010 and it was normal. For contraception, she was previously taking ocp but not really compliance.Past medical history:NilPast surgical history:She had done laparoscopic and dye at 2008 and the result was right tubal block.Family history:Mother has athma, all other members in the family are fine.Social history:She is working as pembantu tabir at PPUKM. She is married for 7 years. Her husband is a instuctor for assistant course.Relevant clinical examinationGeneral examinationPatient looks well and lying comfortably with one pillow. She is communicative and alert. Her vital signs are as follows:Blood pressure : 106/58Pulse rate :82 beats per minuteTemperature :37 degree celciusOn peripheral examination there were no clubbing noted at both of her hands. No pallor and the capillary refill is 2 seconds. There were no palmar erythema noted. Both of her eyes conjunctiva is pink and no yellow discolouration of sclera.Systemic examinationAbdominal examinationUpon inspection of the abdomen. The abdomen is distended by gravid uterus. There is cutaneous signs of pregnancy which are linea nigra and stria gravidarum. The umbilical is centrally located and flat. Otherwise the abdomen is normal. On palpation the uterus is not irritable and the abdomen is soft and nontender. The symphysio fundal height is 38 cm and it is larger than the date. There is two fetus , one in a cephalic presentation and the second twin in transverse presentation. Liquor was adequate.Cardiovascular system examinationRadial pulse is 82 beats per minute and it is in good volume and regular rhythm. Apex beat is felt in 5th intercostal space in midclavicular line. Upon auscultation there is dual rhythm and no murmur heard.Respiratory examinationTrechea is centrally located. There is no respiratory distress. Chest expansion is equal bilaterally. There is vesicular breath sound heard throughout the lungs.Thyroid examinationUpon inspection of the neck there is no thyroid swelling. On palpation there is no throid swelling either and no cervical lymph nodes palpable.Breast examinationUpon inspection the breast has everted nipple and hyperpigmented nipple. There is no skin changes noted. There is no mass felt at both of the breast. The axillary lymph node is not palpable.Diagnosis and differential diagnosisProvisional diagnosis:Twin pregnancy complicated with placenta previa type II posterior.Points for:She is detected to have multiple pregnancy when she was doing antenatal follow up.Her uterus is larger than dateThere are multiple fetal poles can be palpated.Upon latest scan there is two fetal poles detectedUltrasound result showed monochorionic and diamniotic twins(MCDA) so it will lead to larger placental side and lead to placenta previa posterior type IIUltrasound showed the placenta is at posterior and placental edge of 5mm.Points againstThere is no any pervaginal bleeding ar leaking. She is asymptomatic.There is no any signs of anemiaThere is no any serious maternal discomfort due to compression like shortness of breath.There is no pregnancy induced hypertension that is common in pregnancy.There is no any growth restriction.Differential diagnosisAny other differential diagnosis for anterpartum hemorrhage like abruptio placenta, vasa previa and local cervical causesAbruptio placentaPoints for:Multiple pregnancy can give pressure to placenta and cause it to seperate.Points against:It is a emergency condition.My patient didnt develop any acute bleeding.She had no history of trauma to abdomenVasa previaPoints for:Multiple pregnancyPoints againstIt is rare conditionMy patient doesnt have pervaginal bleedingLocal causes like cervical polypsThere is no cervical polyps noted.Relevant investigation with reasonsI would like to doFull blood countThis is to see the hemoglobin level of the patient. Twin pregnancy can lead to anemia.Serum glucose levelThis is to see whether patient has hyperglycemia or not. Twin pregnancy can lead to gestational diabetes mellitus.Urine full examination and microscopic examinationThis is to see if there is any infection which may lead to threatened preterm labour.Ultrasound scanTo see the fetal poles and their lie. To see if there is any abnormally in the twin and to see placental implantation site.Investigation with result1)Full blood countResultUnitsflagNormal rangeWhite Cell Count10.4X109/L+4.0-10.0Red Cell Count3.89X1012/L-4.2-5.4Hemoglobin11.6g/dL-12.0-16.0Hematocrit34.1%-39.0-52.0Mean Cell Volume87.7Fl77.0- 91.0MCH29.9Pg26.0-32.0MCHC34.1g/dL32.0-36.0RDW15.5%++11.3-14.6Mean Platelet Volume9.3Fl6.3-10.2Platelet184X109/L150-400Neutrophils6.8X109/L2.0-7.0Eosinophils0.1X109/L0.02-0.5Basophils0.0X109/L-0.0-0.1Lymphocytes2.8X109/L1.0-3.0Monocytes0.6X109/L0.2-1.0Nucleated Red Blood Cells0X109/L0.0-0.0Impression : my patient has low red cell count and hematocrit value. It suggest anemia which is common in twin pregnancy. She also has elevation of white cell count which is normal inphysiological changes in pregnancy.2) serum glucoseFlag testResultUnitrange2HPP glucose5.3Mmol/L4.0-7.8There is no elevation of glucose.3)UFEME(urinary full examination and microscopic examination)Flag testResultRangeUrine colourYellowUrine clarityClearSpecific gravity1.0151.015-1.025Urine PH85-8Leucocyte25u/lUrine nitrateNegUrine proteinNegUrine glucoseNormUrine ketoneNegUrine urobilinogenNorUrine billirubinNegUrine bloodNegImpression: there is increased in leucocytes. It may indicate infection.Ultrasound scan. Done at 32 weeks of POATwin 1is 32 plus 2 days of gestation with cephalic presentation . liquor was 4.7. Twin 2 is in 32 plus two days of POA and in transverse position with liquor of 3.9. the placenta is placenta previa type II posterior. First twin weighs 1894g and second twin weighs 1886g. other parameters corresponds to date.EBN:Image transcription textTHE EBN PER LEVEL REQUIREMENT A. EBN FORMAT FOR LEVEL II 1. General Question 2. Reconstructionof General Question related to client’s problem identified in the RLE. a. COPES (Client-Oriented PracticalEvidence Search) Client type & problem What might you do Alternate course of action What … Show moreHealth ScienceScienceNursingNCM 102Share Question

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