FutureRN2020
Maternity Case 5: Fatime Sanogo 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).
a.Patient status - Heart rate: 103. Pulse: Present. Blood pressure: 99/51 mmHg. Respiration: 18.
Conscious state: Appropriate. SpO2: 97%. Temp: 37 C
b.Fundus assessment the uterus was soft and boggy.
c.Lochia assessment - minimal redness, minimal edema, no ecchymosis, and no discharge from
the repair, and it is well approximated. A lot of blood and lochia was seen in the vaginal. She
was bleeding at a moderate rate. The increase in weight of the bed pads suggests that
approximately 330 mL of lochia was on the pads. The time since the last change of the pads
suggests a bleeding rate of approximately 1560 mL/hr.
d.pain assessment abdomen area, sharp, severed 5 out 10
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.
a.This is Diana L, calling from postpartum. Calling about a 23 yr. old female Fatime Sanogo
who is postpartum hemorrhages. Heart rate: 103. Pulse: Present. Blood pressure: 99/51
mmHg. Respiration: 18. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C. Blood loss
of 330 ML in 20 minutes, pain scale 5 out of 10. Please advise what to do next?
3.Document the medication(s) you administered to Ms. Sanogo and evaluate each drug’s effectiveness.
a.2 mg of butorphanol tartrate IV . It is important to use the basic rights of medication
administration to ensure proper drug therapy. Patient status - Heart rate: 117. Pulse: Present.
Blood pressure: 95/50 mmHg. Respiration: 21. Conscious state: Appropriate. SpO2: 95%.
Temp: 37 C. b.Bolus of 500 mL of lactated Ringers solution IV , given over 60 minutes. Patient status - Heart
rate: 119. Pulse: Present. Blood pressure: 91/49 mmHg. Respiration: 22. Conscious state:
Appropriate. SpO2: 96%. Temp: 37 C
c.Infusing oxytocin postpartum (mL/hr) at 500 mL/hr. Patient status - Heart rate: 123. Pulse:
Present. Blood pressure: 87/48 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2:
96%. Temp: 37 C.
4.Document the sequence of events during the simulation (i.e., vital signs, assessment findings, blood
loss, nursing interventions, and patient response).
a.Patient status - Heart rate: 106. Pulse: Present. Blood pressure: 100/51 mmHg. Respiration:
20. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C
b.Assisted pt into Trendelenburg position
c.Palpated fundus – uterus soft and boggy
d.Assessed breathing 20 b/min, chest moving equally
e.BP is 98/50, TEMP 37C
f.Washed my hands
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.This study source was downloaded by 100000828906502 from CourseHero.com on 07-06-2021 19:00:29 GMT -05:00
https://www.coursehero.com/file/64825017/MaternityCase05-GRQdocx/This study resource was
shared via CourseHero.com
Maternity Case 5: Fatime Sanogo 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).
a.Patient status - Heart rate: 103. Pulse: Present. Blood pressure: 99/51 mmHg. Respiration: 18.
Conscious state: Appropriate. SpO2: 97%. Temp: 37 C
b.Fundus assessment the uterus was soft and boggy.
c.Lochia assessment - minimal redness, minimal edema, no ecchymosis, and no discharge from
the repair, and it is well approximated. A lot of blood and lochia was seen in the vaginal. She
was bleeding at a moderate rate. The increase in weight of the bed pads suggests that
approximately 330 mL of lochia was on the pads. The time since the last change of the pads
suggests a bleeding rate of approximately 1560 mL/hr.
d.pain assessment abdomen area, sharp, severed 5 out 10
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.
a.This is Diana L, calling from postpartum. Calling about a 23 yr. old female Fatime Sanogo
who is postpartum hemorrhages. Heart rate: 103. Pulse: Present. Blood pressure: 99/51
mmHg. Respiration: 18. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C. Blood loss
of 330 ML in 20 minutes, pain scale 5 out of 10. Please advise what to do next?
3.Document the medication(s) you administered to Ms. Sanogo and evaluate each drug’s effectiveness.
a.2 mg of butorphanol tartrate IV . It is important to use the basic rights of medication
administration to ensure proper drug therapy. Patient status - Heart rate: 117. Pulse: Present.
Blood pressure: 95/50 mmHg. Respiration: 21. Conscious state: Appropriate. SpO2: 95%.
Temp: 37 C. b.Bolus of 500 mL of lactated Ringers solution IV , given over 60 minutes. Patient status - Heart
rate: 119. Pulse: Present. Blood pressure: 91/49 mmHg. Respiration: 22. Conscious state:
Appropriate. SpO2: 96%. Temp: 37 C
c.Infusing oxytocin postpartum (mL/hr) at 500 mL/hr. Patient status - Heart rate: 123. Pulse:
Present. Blood pressure: 87/48 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2:
96%. Temp: 37 C.
4.Document the sequence of events during the simulation (i.e., vital signs, assessment findings, blood
loss, nursing interventions, and patient response).
a.Patient status - Heart rate: 106. Pulse: Present. Blood pressure: 100/51 mmHg. Respiration:
20. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C
b.Assisted pt into Trendelenburg position
c.Palpated fundus – uterus soft and boggy
d.Assessed breathing 20 b/min, chest moving equally
e.BP is 98/50, TEMP 37C
f.Washed my hands
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.This study source was downloaded by 100000828906502 from CourseHero.com on 07-06-2021 19:00:29 GMT -05:00
https://www.coursehero.com/file/64825017/MaternityCase05-GRQdocx/This study resource was
shared via CourseHero.com
