Question

Darlene Hall, a 17-year-old gravida 2 para 1 Caucasian female at 36 weeks' gestation, presented to triage at 0040 Saturday morning with complaints of abdominal pain. Upon admission, Darlene stated that the cause of her pain was a fall onto her buttocks. After asking Darlene's mother to leave the room, the nurse conducted an Intimate Partner Violence (IPV) screen. At that time, Darlene revealed that the actual cause of her injury was a punch to her abdomen, which was delivered by her 25-year-old boyfriend, the father of the baby. She is now in labor. The scenario takes place on Saturday at 0330. During this scenario, students will have the opportunity to determine the impact of intimate partner violence on the maternal-fetal dyad and intervene accordingly.

1.come up with a nursing diagnosis

2. pathophysiologic information related to the medical diagnosis

3.two risk factors related to the medical diagnosis.

Answer 1

1.Come up with a nursing diagnosis

ANSWER:

1. Acute Pain related to muscle contraction as evidence by reports of pain on abdomen.

2. Risk for foetal Injury related to the accident.

3. Anxiety related to situational crisis of threat to self and foetus.

4. Deficient Knowledge related to lack of knowledge secondary to only 17 years old young mother.

2. Pathophysiologic information related to the medical diagnosis

ANSWER:

The three main components contribute to pathophysiology of pre labor are cervical changes, persistent uterine contractions, and activation of the decidua and membranes. The pathophysiology in such condition is that the process of labour occurs in abnormal pathological nature.

In this case, the mother is young only 17 years of age and one of the key events that can occur is the fetal inflammatory response syndrome (FIRS). A signal is sent by the fetal hypothalamus leading to secretion of CRH, stimulating the release of ACTH and therefore cortisol production by the fetal adrenal glands, which triggers the parturition pathway to activate.

3. Two risk factors related to the medical diagnosis.

ANSWER:

1. Preterm labour

2. Foetal injury

3. Risk for mental disorder