Question

“A Difficult Pregnancy” A Nurse Practitioner’s dilemma

“Aaaargh!” Susan P., Family Nurse Practitioner, felt extremely frustrated as she left Room 12. She had just spent the last 30 minutes with Lydia L., a developmentally disabled, 30-weeks-pregnant, 19-year-old Latina. “What’s wrong, Susan?” asked Bernie C.M., the group’s social worker.

“I’ve just spent the last half-hour with Lydia L., you know, the pregnant girl. I’m just so upset! She’s missed several appointments, even though I had the nurses call her. She was late today, as usual. She’s missed several important tests that need to be done during the second trimester. She’s here today with another urinary tract infection because she didn’t finish all the antibiotics from the last infection—they made her sick and she didn’t call us to let us know she had stopped them, even though I gave her specific verbal and written instructions. Now she’s got large quantities of ketones in her urine. On top of that, her blood type is Rh negative. I’ve worked hard to try to prevent anything from happening. I just don’t know what to do!”

“I understand your frustration. What was her excuse for missing the appointments?” asked Bernie. “That’s just it!” exclaimed Susan. “She has no excuse. She just sits there and smiles. She doesn’t seem to hear me. The more I try to talk to her, the quieter she becomes.” “Any luck setting up help for her? I know she’ll need it with her mom out of the picture and her boyfriend working,” said Bernie.

“Another frustration. The red tape. The forms they want filled out. I just know she won’t have any help when that baby comes.” Susan sat down and held her face in her hands. “This is just what I tried to avoid by keeping her here with us in our family practice rather than transferring her to the high-risk clinic at Children’s Hospital. I didn’t want her to ‘get lost,’ but that seems to be exactly what has happened. What should I do?"

A Nurse Practitioner’s Dilemma: Questions, Answers and Option Statement

Questions:

The frustration of the nurse practitioner’s justified.   
True _____ False _____

The nurse practitioner’s understands the clinical care required in Lydia’s case. True ____ False _____

The patient’s psychosocial issues have been adequately addressed.
True _____ False ____

Father’s Rights allow Lydia’s boyfriend to make decisions about the medical care of the unborn child. True _____ False _____

This the right time in Lydia’s coordinated care for the NP to recommend Lydia for a consultation with Social Work? True _____ False _____

Then briefly discuss how you would address at least 3 of the issues on Lydia’s Case.   

In your discussion consider:

How would you treat the various problems?

What are the psychosocial issues?

What are the ethical issues?

How would you feel caring for this patient?

Answer 1

The frustration of the nurse practitioner’s justified. True.

The nurse practitioner understands the clinical care required in Lydia's case. True.

The patient’s psychosocial issues have been adequately addressed. True.

Father’s Rights allow Lydia’s boyfriend to make decisions about the medical care of the unborn child. False.

This the right time in Lydia’s coordinated care for the NP to recommend Lydia for a consultation with Social Work? False.

How would you treat the various problems?

1. It's found that Lydia's suffering from urinary tract infection

Since Lydia did not complete the course of antibiotics for the last UTI, antibiotics need to be prescribed again and advise her to drink plenty of liquids.

2. Presence of large quantities of ketones in urine:

The appearance of ketones in urine during pregnancy may be associated with drastic lack of nutrients in the body (especially with the lack of carbohydrates). An unbalanced diet, when a woman eats too much protein and fat can also be the cause.Increased body weight can be the reason for high levels of acetone in the urine during the second trimester of pregnancy. Lydia's dietary pattern has to be assessed and changes made accordingly​. Encourage her to drink plenty of liquids and take adequate rest. Ask her to avoid fried foods, sweets and citrus fruits.

What are the psychosocial issues?

Lydia being a 19 year old, developmentally disabled pregnant woman faces certain psychosocial issues such as:

Being developmentally disabled, she does not have the intellectual capacity to comprehend things or maintain self care and has very little social support during this crucial time, with only a boyfriend who has little time to care for her as he's working. She is in need of help throughout her pregnancy and with the care of the baby.

What are the ethical issues?

Some of the ethical issues faced are:

The care of the unborn child rests with Lydia and she has the right to make decisions about her medical care though she seems to be unsuccessful at keeping up the appointments, tests, or treatment. Her boyfriend cannot be involved in decision making. This creates an ethical dilemma in the interest of the wellbeing of the mother and child.

How would you feel caring for this patient?

If I had to care for Lydia, I would also be facing the same ethical dilemma and find it difficult to plan the course of her medical care. But I would empathise with her and try to be patient in trying to make her understand the care she needs to take, and would involve her boyfriend in her routine medical care.