Maternity Case 10: Fatime Sanogo (Complex) Documentation Assignments.

Maternity Case 10: Fatime Sanogo (Complex) Documentation Assignments 1. Document your initial assessment data for Ms. Sanogo, including vital signs, fundal assessment (consistency, position, location), lochia assessment (amount, color, odor, consistency), and pain (location, quality, severity). VS: B/P 100/51, pulse 103, respirations 18, SpO2 97%, temperature 37.0. I examined the patient’s chest which found breasts are soft and nipples intact, no bruising. She is breathing at 19 breaths per minute. The chest is moving equally, and there is no tenting sign of the skin. Her color is normal, and she is not sweating. No edema present. Lung sounds clear and equal bilaterally; Heart sounds regular without murmurs. IV site had no redness, swelling, infiltration, bleeding, or drainage; dressing dry and intact. There was minimal redness, minimal edema, no echimosis, and no discharge from the repair, and edges were well approximated to perineum. A lot of blood and lochia was seen in the vagina; the bleeding was at a moderate rate. I weighed the bed pads and they suggest 1210 mL of lochia was on the pads. The time since the last change of the pads suggests a bleeding rate of approximately 1980 mL/hr. The uterus was soft abd boggy. Fundal massage was performed, and the uterus did not firm up properly. Bladder was assessed with 300 mL of urine. Straight catheterization was performed. Provider was phoned. 2. Write the situation-background-assessment-recommendation (SBAR) communications you would use to update the provider on Ms. Sanogo’s status after your first encounter with her. Situation: Fatime Sanogo is a 23-year-old primiparous female in her first hour after delivery. Patient was admitted yesterday at 0600 hours for oxytocin induction of labor secondary to postdates (41 4/7 weeks). She has declined all pain medication during labor. Background: Patient contracted a second-degree perineal laceration during delivery; this has been repaired. Placenta was delivered manually at 0635 hours via Dr. Schultz. Bleeding was controlled by fundal massage and infusion of remaining oxytocin induction bag. Assessment: Patient has not been able to void and straight catheter was ordered and placed on patient. Patient had moderate bleeding and hypotension. Dr ordered 5mg Morphine IV for patient’s “belly” pain. Once administered the patient reported her pain from a “5” to a “2”. Butorphanol Tartrate IV 2mg PRN for patients’ pain. The patient’s pain was reduced. Misoprostol 800 mcg rectal to increase uterine contraction to control and reduce bleeding. Lactated Ringers IV bolus 500 ml to help with patient’s low blood pressure. Patients’ blood pressure increased. Oxytocin Postpartum IV 500 ml/hr. helps decrease patients bleeding. The bleeding was reduced. Recommendation: Continue with orders and monitor patient continuously for bleeding and perform fundus massages. 3. Document the medication(s) you administered to Ms. Sanogo and evaluate each drug’s effectiveness.