Case three: trend and matrix
one time axis carrying two curves, a rising line labeled DISEASE tracing blood pressure and a falling line labeled THERAPY tracing respiratory rate and reflex grade, with the falling line entering a shaded zone at 1600.
THE CASE
Ms. A, 31 years old, is on postpartum day 1 after a spontaneous vaginal birth at 38 weeks. She was admitted at term with gestational hypertension and is receiving magnesium sulfate by continuous infusion for seizure prophylaxis. She reports a headache she rates 7 out of 10, unrelieved by the acetaminophen given two hours ago, and says the room lights look "swimmy." Fundus firm at the umbilicus. Lochia rubra, moderate. Indwelling urinary catheter in place.
THREE TIME POINTS
| 0800 | 1200 | 1600 | |
|---|---|---|---|
| Blood pressure | 148/92 | 162/104 | 168/110 |
| Heart rate | 88 | 84 | 80 |
| Respiratory rate | 18 | 14 | 10 |
| Deep tendon reflexes | 2+ | 1+ | absent |
| Urine output | 60 mL/hr | 35 mL/hr | 18 mL/hr |
| Oxygen saturation | 98% | 96% | 93% |
| Platelet count | 148,000/mm³ | 121,000/mm³ | 96,000/mm³ |
| New findings | none | none | right upper quadrant pain |
TREND ITEM
66a. Select the three findings whose trajectory across the three time points indicates that the therapy, rather than the disease, is now harming the client.
- Deep tendon reflexes 2+ to 1+ to absent
- Respiratory rate 18 to 14 to 10
- Urine output 60 to 35 to 18 mL per hour
- Blood pressure 148/92 to 162/104 to 168/110
- Platelet count 148,000 to 121,000 to 96,000/mm³
- Oxygen saturation 98% to 96% to 93%
66b. Which finding at 1600, taken together with the platelet trend, indicates that the disease process is also worsening?
- Heart rate of 80
- New right upper quadrant pain
- Lochia rubra, moderate
- Oxygen saturation of 93%
MATRIX GRID
For each finding, select one column.
| Finding | INTERVENE NOW | MONITOR AND REASSESS | EXPECTED FINDING |
|---|---|---|---|
| Absent deep tendon reflexes | ☐ | ☐ | ☐ |
| Respiratory rate 10 | ☐ | ☐ | ☐ |
| Urine output 18 mL per hour | ☐ | ☐ | ☐ |
| Blood pressure 168/110 | ☐ | ☐ | ☐ |
| Lochia rubra, moderate, on postpartum day 1 | ☐ | ☐ | ☐ |
| New right upper quadrant pain | ☐ | ☐ | ☐ |
Margin note: "reflexes go before the breathing does."
> Watch out: an absent reflex during a magnesium sulfate infusion is an action, not an observation. > → BOOK 12 · P9 and → BOOK 05 · P11
Takeaway. Two processes can deteriorate on the same flowsheet, and the trend column is where you see the second one.