Student Name: Fariyal Chowdhury _ Date:_4.17.2020___
Instructor: Professor Michels _ Group 4 VSIM : Brenda Patton
SBAR of Patient Condition
Situation:
a
My name is Fariyal. Patient Brenda Patton is G1P0 at 38 2/7 weeks of gestation admitted to the labor and birthing unit for labor
vi
assessment. She is positive for Group B vaginorectal culture and is experiencing contractions. Vaginal exam reveals 50%
effacement of cervix, cervical dilation 4 cm, and fetus at -2 station.
e d
Background:
ar
Brenda Patton is an 18-year-old Caucasian female, G1P0 at 38 2/7 weeks of gestation admitted to the labor and birthing unit for
sh
labor assessment. The patient states that her water may have broken earlier this morning and she thinks she is in labor. AmniSure
was positive. The patient's boyfriend is present, and she has phoned her mother to inform her of her admission. The provider has
been notified, and prenatal records have been pulled. The lab report indicates that the patient's group B strep vaginorectal culture
as
taken at 36 weeks was positive. The patient wishes to have a natural birth without medication. Admission intrapartum orders have
been initiated, initial labs have been drawn, and a saline lock has been placed in her forearm.
w
Assessment:
m e
Her current vital signs are: HR: 88 BPM. Pulse: present. BP: 117/70 mmHg. RR: 20. LOC: appropriate. SPO2: 97%. Temp: 37C.
co rc
Uterus was soft between contractions. Contractions were regular with moderate intensity with each contraction being 4-5 minutes
o. ou
apart, approximately 50 seconds each. 300 mL of clear, amniotic fluid was noted on the pad where the membrane had ruptured. The
fetal baseline heart rate is 149 which showed periods of episodic acceleration.
er res
Recommendations:
eH y
I recommend that vital signs be taken every 30 minutes due to rupture of membrane. Continue to monitor fetal heart rate for
rs ud
possible signs of fetal distress due to GBS. Provide supportive care. Take note of any signs of maternal or fetal distress.
t
ss
hi
, Student Name: Fariyal Chowdhury _ Date:_4.17.2020___
Instructor: Professor Michels _ Group 4 VSIM : Brenda Patton
Plan of Care
Nursing Diagnosis Expected Outcomes Nursing Plan / Scientific Rationale for Evaluation
Interventions each intervention
a
(include reference
source)
vi
Acute pain related to Short Term: 1. Patient will use 1. This will help decrease 1. patient verbalizes and
uterine contraction as relaxation techniques, muscle tension, perception demonstrates
d
evidenced by contractions 1. Patient uses such as deep breathing of pain, and sense of nonpharmacological pain
e
every 4-5 minutes apart nonpharmacological pain exercises, visualization, control over pain management strategies
each lasting management strategies by such as deep breathing
ar
guided imagery
approximately 50 seconds end of nursing shift (Gulanick & Myers, 2017, exercises and guided
p. 327) imagery
sh
2. Patient exhibits 2. Assess for signs and
increased comfort levels symptoms of pain and 2. Using a numeric pain 2. Patient’s vital signs are
for pulse, BP, use a numeric rating scale will help identify stable and demonstrates a
as
respirations, relaxed scale to identify pain intensity of pain; vital focused and calm
muscle tone by end of signs may be elevated demeanor
w
nursing shift 3. Reassure to patient when patient is in pain and
that the pain is temporary patient’s skin may be pale 3. Patient verbalizes
m e
Long Term: and there is more than and cool to the touch; stability of pain
patient may also appear
co rc
3. Patient reports
satisfactory pain control
one approach to easing
pain restless and have difficulty
concentration
4. Patient verbalizes
feeling relaxed and not
o. ou
discharge overly exhausted
4. Provide rest periods to (Gulanick & Myers, 2017,
facilitate comfort, sleep
er res
4. Patient will appear p. 328)
more relaxed and rest and relaxation
appropriately by 3. when pain is perceived
discharge as everlasting, the patient
eH y
may give up trying to cope
rs ud
and will have a loss of
control. Reassurance will
encourage the patient to
t
continue following
ss
hi
Instructor: Professor Michels _ Group 4 VSIM : Brenda Patton
SBAR of Patient Condition
Situation:
a
My name is Fariyal. Patient Brenda Patton is G1P0 at 38 2/7 weeks of gestation admitted to the labor and birthing unit for labor
vi
assessment. She is positive for Group B vaginorectal culture and is experiencing contractions. Vaginal exam reveals 50%
effacement of cervix, cervical dilation 4 cm, and fetus at -2 station.
e d
Background:
ar
Brenda Patton is an 18-year-old Caucasian female, G1P0 at 38 2/7 weeks of gestation admitted to the labor and birthing unit for
sh
labor assessment. The patient states that her water may have broken earlier this morning and she thinks she is in labor. AmniSure
was positive. The patient's boyfriend is present, and she has phoned her mother to inform her of her admission. The provider has
been notified, and prenatal records have been pulled. The lab report indicates that the patient's group B strep vaginorectal culture
as
taken at 36 weeks was positive. The patient wishes to have a natural birth without medication. Admission intrapartum orders have
been initiated, initial labs have been drawn, and a saline lock has been placed in her forearm.
w
Assessment:
m e
Her current vital signs are: HR: 88 BPM. Pulse: present. BP: 117/70 mmHg. RR: 20. LOC: appropriate. SPO2: 97%. Temp: 37C.
co rc
Uterus was soft between contractions. Contractions were regular with moderate intensity with each contraction being 4-5 minutes
o. ou
apart, approximately 50 seconds each. 300 mL of clear, amniotic fluid was noted on the pad where the membrane had ruptured. The
fetal baseline heart rate is 149 which showed periods of episodic acceleration.
er res
Recommendations:
eH y
I recommend that vital signs be taken every 30 minutes due to rupture of membrane. Continue to monitor fetal heart rate for
rs ud
possible signs of fetal distress due to GBS. Provide supportive care. Take note of any signs of maternal or fetal distress.
t
ss
hi
, Student Name: Fariyal Chowdhury _ Date:_4.17.2020___
Instructor: Professor Michels _ Group 4 VSIM : Brenda Patton
Plan of Care
Nursing Diagnosis Expected Outcomes Nursing Plan / Scientific Rationale for Evaluation
Interventions each intervention
a
(include reference
source)
vi
Acute pain related to Short Term: 1. Patient will use 1. This will help decrease 1. patient verbalizes and
uterine contraction as relaxation techniques, muscle tension, perception demonstrates
d
evidenced by contractions 1. Patient uses such as deep breathing of pain, and sense of nonpharmacological pain
e
every 4-5 minutes apart nonpharmacological pain exercises, visualization, control over pain management strategies
each lasting management strategies by such as deep breathing
ar
guided imagery
approximately 50 seconds end of nursing shift (Gulanick & Myers, 2017, exercises and guided
p. 327) imagery
sh
2. Patient exhibits 2. Assess for signs and
increased comfort levels symptoms of pain and 2. Using a numeric pain 2. Patient’s vital signs are
for pulse, BP, use a numeric rating scale will help identify stable and demonstrates a
as
respirations, relaxed scale to identify pain intensity of pain; vital focused and calm
muscle tone by end of signs may be elevated demeanor
w
nursing shift 3. Reassure to patient when patient is in pain and
that the pain is temporary patient’s skin may be pale 3. Patient verbalizes
m e
Long Term: and there is more than and cool to the touch; stability of pain
patient may also appear
co rc
3. Patient reports
satisfactory pain control
one approach to easing
pain restless and have difficulty
concentration
4. Patient verbalizes
feeling relaxed and not
o. ou
discharge overly exhausted
4. Provide rest periods to (Gulanick & Myers, 2017,
facilitate comfort, sleep
er res
4. Patient will appear p. 328)
more relaxed and rest and relaxation
appropriately by 3. when pain is perceived
discharge as everlasting, the patient
eH y
may give up trying to cope
rs ud
and will have a loss of
control. Reassurance will
encourage the patient to
t
continue following
ss
hi
