FutureRN2020 Maternity Case 1: Olivia Jones

FutureRN2020 Maternity Case 1: Olivia Jones FutureRN2020 Maternity Case 1: Olivia Jones Documentation Assignments 1. Document the data from your focused antepartum assessment of both Ms. Jones and the fetus. a. My main focus was to maintain the patient’s safety, placing seizure pads and reducing the outside stimulus. Assessing the patient’s vital signs, attaching the fetal heart rate monitor and performing a head to assessment. You examined the patient abdomen and pelvis. Leopold’s maneuver was performed. The fetus is in longitudinal lie, in vertex presentation. 2. Write the situation-background-assessment-recommendation (SBAR) communications you would use to update the provider on Ms. Jones’s status at the time of her admission. a. S: Olivia Jones 23 yr. /old African American female, G1 P0 at 36 weeks of gestation admitted to L&D for assessment and observation. b. B: at 30 weeks patient had an elevated BP 146/92, proteinuria and developing mild preeclampsia. c. A: Patient status - Heart rate: 110. Pulse: Present. Blood pressure: 168/101 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 93%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 152 d. R: Continuously monitoring BP, HR & RR & O2. Continue monitoring fetal heart rate, and providing comfort measures. 3. Document the teaching you would provide to the patient and her support person prior to administering magnesium sulfate. a. Educate the patient and her support that magnesium sulfate is used to prevent seizure activity and educate them about the signs and symptoms of toxicity and to report adverse effects immediately. 4. Document the administration of the magnesium sulfate bolus and the initiation of the magnesium sulfate infusion. a. Doctor called in an order for magnesium sulfate in sterile water (6g in 100 mL) at 200 mL/hr. It is important to use the basic rights of medication administration to ensure proper drug therapy. This was indicated by order. Verified order with a second nurse was done before administration. Magnesium sulfate 20 mg in 500 ml in sterile water at 50 ml/hr. was not given because the first dose was still being infused. 5. Document your reassessment of the patient’s status after administering magnesium sulfate. a. Following administration of magnesium sulfate doctor ordered to have patient’s vital signs reassessed q 15 minutes and every hour after infusion. After administration there were no changes in the patient’s status.