MOS 6301 Columbia Southern Workplace Controls for Health Hazards Controls Project A very important part of the Industrial Hygiene profession is reducing th

MOS 6301 Columbia Southern Workplace Controls for Health Hazards Controls Project A very important part of the Industrial Hygiene profession is reducing the risk associated with health hazards. This requires the IH to be familiar with workplace controls. OSHA has used the Hierarchy of Controls as an acceptable approach to recommending and implementing controls for reducing risks in the workplace. Make sure you are familiar with the Hierarchy of Controls. The controls at the top of the pyramid are the most effective at reducing risk. Most facilities will not be able to eliminate a hazard or substitute a hazard with another that has less risk, because of requirements for production. Therefore, for health hazards the most commonly used controls tend to be engineering controls, and for airborne exposures, ventilation is the most commonly used engineering control. The readings this week are from textbook Fuller, T. P. (2015). Essentials of industrial hygiene. Itasca, IL: National Safety Council. Chapters 1, 8, and 11. also see web page and a power point presentation in the study guide please review. The assignment this week consists of two parts please combine into one submittal. In the first part, you will discuss the use of two types of ventilation systems to reduce the concentrations of airborne health hazards in the AAP facility. In the second part you will discuss engineering controls for the noise exposures in the hydraulic press area of AAP. NUR 115
Suzanne Case Study Rubric
Name:
Criteria
1 Determine patient risk
factors for preeclampsia and
map initial status.
2 Evaluate change in patient
status and implications for a
developing complication.
3 What is the CMQCC
recommended health team
response for this patient?
4 Rationale for order to
evaluate lung sounds
5 Map change in patient status
and implications for a
developing complication.
6 What is the CMQCC
recommended health team
response for this patient?
7 SBA2R3 Report
8
Staff notifications and
rationales.
9
Discuss appropriateness of
the orders given.
10 Adverse effects of Magnesium
Sulfate therapy that must be
reported.
11 Problems of the 32-week
preterm newborn.
12 Appropriate postpartum bed
assignment
13 Maternal discharge teaching.
14 Criteria for discharge from
NICU Care
Total Points:
Notes
Points Yours
10
10
5
5
10
10
15
5
5
5
5
5
5
5
100
SBA2R3 Report
SBA2R3 Elements
Notes
SITUATION:
PRIMARY PROBLEM
Origin
Course
Current Status
BACKGROUND:
RELEVANT history
ASSESSMENT/ANALYSIS:
Current Vital Signs:
RELEVANT Physical
Assessments:
Mental Status:
RELEVANT Labs/Diagnostics:
TRENDS of Abnormal Findings:
Unstable, Stable,
Worsening, Improving
Patient Response to
Interventions:
RECOMMENDATIONS/
RATIONALES:
Changes in treatment plan
MD to see this patient now
ICU/CCU transfer
New Labs/Diagnostics
New Medications
Specialty Consultation
RESPONSE
Questions
Discussion
Agreement on action plan
As Dr. Allen is this patient’s admitting physician, and he has been updated on
her status throughout the night, you do not need to provide patient
background information.
MOUNT WACHUSETT COMMUNITY COLLEGE
DEPARTMENT OF NURSING
NUR 115 PREECLAMPSIA CASE STUDY
SUMMER, 2020
YOUR TEXT PAGES 172-178 WILL BE HELPFUL FOR THIS ASSIGNMENT.
STUDENT______________________________________________
SITUATION:
January 11th, 2019
19:00
Suzanne M. has come to the Labor and Delivery unit at a Level III (NICU) hospital with an admitting diagnosis
of “Rule out Preeclampsia.” Dr. Allen, her obstetrician, has written these orders:
Assessments:
Fetal non-stress test for each twin, then continuous electronic fetal monitoring.
Vital Signs:
Blood pressure on admission and every 15 minutes in semi-Fowler’s position
Respiratory assessment on admission, hourly and as needed
Continuous pulse oximetry
Pre-eclampsia assessments hourly and as needed:
Level of consciousness
Headache
Visual changes
Abdominal or Chest Pain
Deep tendon reflexes and clonus
Activity:
Bed rest with bathroom privileges.
Labs:
Clot and hold for possible future type and cross match.
CBC
Liver enzymes (AST, ALT)
Serum creatinine
Urinalysis
Phone report to Dr. Allen as soon as lab results are available.
Background:
Suzanne is a G3P0 who is pregnant again through in vitro fertilization (IVF) with twins. Now at 32 weeks, this
pregnancy has gone well so far. She has no chronic health conditions. She is CEO of the tech company she
started, and the business is thriving.
1
Suzanne read something on the web about preeclampsia last week. She is very interested in this topic because
her own mother, Maris, had preeclampsia when she was pregnant with Suzanne (Maris’s first child) and again
during her fifth and final pregnancy. Suzanne herself did not experience preeclampsia in her first two
pregnancies, both of which ended spontaneously early in the second trimester.
When Suzanne started feeling strange today, she remembered the article and called for an urgent
appointment with her obstetrician. In the office, Dr. Allen listens attentively to Suzanne’s vague complaints,
and her concern that she might have preeclampsia. He notes that Suzanne does not have any peripheral
edema, but her blood pressure is mildly elevated at 138/86, and a urine dip shows a trace of protein.
Dr. Allen’s general attitude is that pregnant women are often unduly influenced by alarmist information they
read on the web, but he also believes he should act on patient concerns, no matter how groundless they may
seem. Although nothing he had heard or seen during the appointment concerned him, he sends Suzanne to
the L&D unit for labs, blood pressure monitoring, and a non-stress test on the twins, just to be thorough.
1.
a. (5 pts) According to the list of Risk Factors for Preeclampsia found on page 174 of your text, what
risk factors are present in Suzanne M.’s history and current situation?
b. (5 pts) Map current assessments onto the CMQCC Preeclampsia Early Recognition Toolkit Table.
Assessment
Systolic BP 138
Diastolic BP 86
Proteinuria: Trace
Normal
Worrisome
Severe
ASSESSMENTS:
The nurse orients Suzanne to the labor room, explains procedures, and asks her to change into a hospital
gown to facilitate the NST for the two babies. She instructs Suzanne on collecting the urine specimen for
urinalysis, initiates the NSTs, begins ordered assessments, and facilitates lab specimen collection.
Suzanne is alert and oriented, giving directions over the phone to her administrative assistant for managing
aspects of her business while she (Suzanne) is in the hospital. Both Suzanne and Dr. Allen believe this will be a
short stay to confirm the absence of preeclampsia.
January 11th,
20:20 – lab results are available.
2
2. (10 pts) Map lab and assessment findings to the CMQCC Preeclampsia Early Recognition Toolkit Table.
Assessments
Vital Signs
Systolic Blood Pressures Range
Diastolic Blood Pressure Range
Respiratory Assessments
Pulse Oximetry
Preeclampsia Assessments
Level of Consciousness
Headache, N/V
Visual Changes (Blurred)
Abdominal/Chest Pain
DTR’s/Clonus
Labs
Platelets
Liver Enzymes (ALT/AST)
Serum Creatinine
Urinalysis
Non-Stress Test/Fetal Monitoring
Fetus A
Fetus B
Findings/Results
Normal
Worrisome
Severe
140 to 156
80 to 88
14 to 22; no SOB
≥ 95% on RA
Alert and Oriented
Denies
Denies
Denies
2+, no clonus
N/A*
150k
53/67
0.9
+1 protein
Reactive, Category I
Reactive, Category I
* Considered in the CMQCC Protocol only if the patient is on magnesium sulfate IV therapy.
3. (5 pts) What is the CMQCC recommended health team response for this clinical picture?
NEW ORDERS
January 11th 21:00
After receiving report from the nurse, Dr. Allen orders over-night observation, continuing all assessments,
extending blood pressure assessments to hourly instead of every 15 minutes and allowing patient to assume a
side-lying position for sleeping comfort. Labs are to be repeated at 06:00 and results called to the physician as
soon as available.
CONTINUING ASSESSMENTS
During the night, Suzanne becomes nauseous and vomits several times. At 02:00 the nurse reports this to the
physician and requests an order for Zofran (ondansetron). The physician complies, adding orders for IV
3
Lactated Ringers at 125 mL/hour, NPO status, and a Foley catheter with careful calculation of fluid intake and
output.
4. (5 pts) The physician also adds lung sounds to the respiratory assessment. Why is this necessary?
Over the night shift, Suzanne vomits a total of 1700mL. She declines the Zofran for the nausea and does not
sleep well. Ordered labs are drawn at 06:00. Between 06:00 and 07:30, Suzanne becomes alternately
confused/agitated and somnolent. At 07:20, the nurse enters the room to find her sitting up on the edge of
the bed, Johnny removed, trying to get up to go to the bathroom because she has to pee. The nurse helps her
get back into her Johnny and back to bed, explaining that the presence of the Foley means she doesn’t have to
go to the bathroom to pee. Suzanne tells the nurse, “I’m really out of it, aren’t I.”
5. (10 pts) Map the new assessments and lab results to the CMQCC Preeclampsia Early Recognition
Toolkit Table.
Assessments
Vital Signs
Systolic Blood Pressures Range
Diastolic Blood Pressure Range
Respiratory Assessments
Pulse Oximetry
Preeclampsia Assessments
Level of Consciousness
Headache, N/V
Visual Changes (Blurred)
Abdominal/Chest Pain
DTR’s/Clonus
Fluid Intake & Output
Urine Output
Labs
Platelets
Liver Enzymes (ALT/AST)
Serum Creatinine
Non-Stress Test/Fetal Monitoring
Fetus A
Fetus B
Findings/Results
Normal
Worrisome
Severe
158-164
98-108
14-18, no SOB, clear
≥ 95%
Confused, agitated
Nausea & Vomiting
Denies
Denies
3+, no clonus.
625/1825
125 over 5 hours
N/A*
N/A**
96
73/116
1.0
Category I
Category II
*Not considered under the CMQCC Protocol unless the patient is on magnesium sulfate IV therapy. Many practitioners consider
increasing DTR’s, especially with clonus, to be indicative of increased CNS tone and predictive for seizure.
** Not considered under the CMQCC Protocol, however essential for the patient who is on IV fluids, especially when the patient is at
risk for fluid imbalance due to vomiting, or on magnesium sulfate IV therapy.
4
6. (5 pts) What is the CMQCC recommended health team response for this clinical picture?
7. (15 pts) Prepare an SBA2R3 report for this patient’s change of status.
NEW ORDERS
January 12th 07:40
Dr. Allen receives the nurse’s SBA2R3 report, which includes a current blood pressure of 180/110 and
continued agitation/confusion alternating with somnolence. Dr. Allen states that he will arrive in about 30
minutes and gives these telephone orders:
Face-to-face evaluation by senior obstetric resident physician now.
Magnesium Sulfate 4 grams in 100 mL NS IV over 20 minutes followed by
Magnesium Sulfate 2 grams/hour.
Labetalol 20 mg IVP over 2 minutes. If not effective in bringing BP below 160/105-110,
Then escalate doses (40 mg, then 80 mg) IVP every 20 minutes.
Total not to exceed 220 mg in 24 hours.
BP Goal: 140-150/90-100.
Dosing and response to be supervised by senior obstetric resident physician.
Blood type and cross match for 2 units packed red blood cells.
Notify appropriate personnel of likely C-Section birth of twins at 32 weeks gestation.
8. (5 pts) Who are the “appropriate personnel” who should be notified about this patient’s change of status
and the potential track her treatment may soon be following? Why? (Use your clinical imagination!)
Who should be notified?
Why?
5
9. (5 pts) Are these orders appropriate, considering CMQCC recommendations and the patient’s current
status? Were some recommended orders omitted? Why do you think that might be? Support your answer
with evidence- based rationales.
10. (5 pts) From your text book, (Bottom of page 177 to page 178 – “Care of the Woman on Magnesium
Sulfate”) list 7 abnormal maternal assessments that must be reported to the obstetrician.
January 12th 08:20
By the time Dr. Allen arrives, the obstetric resident physician has been in to evaluate the patient, the
magnesium sulfate bolus has been delivered, and magnesium is now infusing at a rate of 2 grams/hour. All
assessments related to preeclampsia and magnesium sulfate therapy have been normal, except for Suzanne’s
cognitive status. Her blood pressure is within the target range (140-160/90-100) and she is hemodynamically
stable.
The patient’s husband Thom has arrived and is acting as health care proxy for Suzanne, who is not fully
capable of participating in decisions. Considering Suzanne’s cognitive status, and that both fetuses are now
experiencing fetal heart rate changes that define Category II, the difficult decision is made collaboratively to
proceed with C-section birth of the babies at 32 weeks. The plan moves forward quickly, and both babies are
now stable and in the care of the NICU teams.
11. (5 pts) Anticipate the five main health concerns/needs of infants born at 32 weeks gestation (moderately
preterm). List and briefly describe.
https://www.verywellfamily.com/what-is-a-moderately-preterm-baby-2748626
While Suzanne is recovering in the Post Anesthesia Care Unit (PACU), there is an inter-professional discussion
as to whether she should be transferred to the Postpartum Unit, to the Intensive Care Unit (ICU), or back to
the Labor & Delivery Unit. Advantages and disadvantages of each location are listed here.
Care Unit
Postpartum Unit
Advantages
More homey environment, less stimulating
(quieter) than L&D or ICU.
Closest proximity to the NICU for visiting babies.
Labor & Delivery Unit
Nursing expertise with
Disadvantages
Lack of nursing expertise with
magnesium sulfate therapy management
Preeclampsia, Eclampsia, HELLP Syndrome
Higher ratio of patients to nursing staff
Not enough nursing staff to take Suzanne to the
NICU to visit, or to care for the babies were they
to come visit mom here.
Unpredictable ratio of patients to nursing staff
6
Intensive Care Unit
magnesium sulfate therapy management
Preeclampsia, Eclampsia, HELLP Syndrome
Closer proximity to the NICU for visiting babies.
1:1 nursing care around the clock is the standard.
Nursing expertise with addressing systems
dysfunctions associated with Preeclampsia,
Eclampsia, and HELLP, and complications of
magnesium sulfate therapy.
Staff sufficient in number and knowledge/skill to
manage any complication that may arise.
High census of laboring mothers may mean
less attention to Suzanne with increased
risk of complications.
Noisy, fast paced environment with little privacy.
Farthest from the NICU for visiting.
Protocols would prohibit mother from leaving to
visit NICU. Babies require intensive care too and
cannot come to ICU to visit with mother.
If recovery goes well, Suzanne will not be sick
enough to require ICU care for very long.
12. (5 pts) Considering that Suzanne will be on Magnesium Sulfate for another 24 hours, that her cognitive
status is still abnormal, and that the risks of Eclampsia and HELLP Syndrome do not end with the birth of the
babies, which Unit would be the best placement for Suzanne and Why.
January 16th 15:00
Suzanne’s recovery has gone well and she is ready for discharge on postop day #4. She will be staying at the
hospital in a “boarder room” so she can be close to her babies, who are expected to be ready for discharge in
about 3 weeks. Her discharge teaching form is available in this folder.
13. (5 pts) Suzanne looks over the discharge teaching sheet and asks, “What does this mean? I thought I was
out of the woods at this point, but I could get sick again?” Construct a thoughtful response that will help
Suzanne to comply with self-monitoring but not frighten her.
14. (5 pts) List and briefly describe the milestones that a preterm infant must achieve before discharge home.
https://www.verywellfamily.com/milestones-a-nicu-baby-must-reach-before-discharge-2748598
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