Maternity Case 1: Olivia Jones
Documentation Assignments
1. Document the data from your focused antepartum assessment of both Ms. Jones and the fetus.
a. First I put up seizure pads and minimized outside simuli. I assessed the pts VS, applied
oxygen, attached the FHR, and performed a head to toe assessment. The fetus was in
longitudinal lie, in vertex presentation and and FHR was WNL.
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.
Olivia Jones is a 23 year old African American female, G1PO at 36 weeks of gestation admitted to
m
er as
L&D for assessment and surveillance. Around 30 weeks pt had an elevated BP of 146/92, proteinuriam
and was developing mild preeclampia. She was admitted with increasing symptoms: Protein dipstick +4,
co
eH w
negative ketones and glucose, +2 dependent edma, and facial puffiness. Pt is experiencing nausea ,
fatigue, and headaches not relieved by acetaminophen. Seizures pads were places, outside stimuli was
o.
rs e
minimized, VS were assessed, pt had increased BP: 170/104, oxygen was applied as per dr orders, FHR
ou urc
was WNL, a urinary catheter was placed, and magnesium sulphate in sterile water is infusing.
3. Document the teaching you would provide to the patient and her support person prior to
o
administering magnesium sulfate.
aC s
I would inform the pt and her support person that magnesium sulfate is used to prevent seizure
vi y re
activity and of the signs and symptoms of toxicity and to report any adverse effects immediately.
4. Document the administration of the magnesium sulfate bolus and the initiation of the magnesium
ed d
sulfate infusion.
ar stu
The dr ordered Mag sulfate 6g in 100 mL in sterile water at 200 mL/hr, and a second nurse
needs to witness administration, mag sulfate 20 mg in 500 mL in sterile water at 50 mL/hr should not
have been started since the first dose was still infusing.
is
5. Document your reassessment of the patient’s status after administering magnesium sulfate.
Th
After administering mag sulfate the dr ordered for the pts pulse, BP, and RR to be monitored
every 15 minutes and every hour after infusion, after administration there was no changes in pts
sh
status.
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
This study source was downloaded by 100000796901680 from CourseHero.com on 04-01-2021 17:09:04 GMT -05:00
https://www.coursehero.com/file/46535657/jones-DA/
Documentation Assignments
1. Document the data from your focused antepartum assessment of both Ms. Jones and the fetus.
a. First I put up seizure pads and minimized outside simuli. I assessed the pts VS, applied
oxygen, attached the FHR, and performed a head to toe assessment. The fetus was in
longitudinal lie, in vertex presentation and and FHR was WNL.
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.
Olivia Jones is a 23 year old African American female, G1PO at 36 weeks of gestation admitted to
m
er as
L&D for assessment and surveillance. Around 30 weeks pt had an elevated BP of 146/92, proteinuriam
and was developing mild preeclampia. She was admitted with increasing symptoms: Protein dipstick +4,
co
eH w
negative ketones and glucose, +2 dependent edma, and facial puffiness. Pt is experiencing nausea ,
fatigue, and headaches not relieved by acetaminophen. Seizures pads were places, outside stimuli was
o.
rs e
minimized, VS were assessed, pt had increased BP: 170/104, oxygen was applied as per dr orders, FHR
ou urc
was WNL, a urinary catheter was placed, and magnesium sulphate in sterile water is infusing.
3. Document the teaching you would provide to the patient and her support person prior to
o
administering magnesium sulfate.
aC s
I would inform the pt and her support person that magnesium sulfate is used to prevent seizure
vi y re
activity and of the signs and symptoms of toxicity and to report any adverse effects immediately.
4. Document the administration of the magnesium sulfate bolus and the initiation of the magnesium
ed d
sulfate infusion.
ar stu
The dr ordered Mag sulfate 6g in 100 mL in sterile water at 200 mL/hr, and a second nurse
needs to witness administration, mag sulfate 20 mg in 500 mL in sterile water at 50 mL/hr should not
have been started since the first dose was still infusing.
is
5. Document your reassessment of the patient’s status after administering magnesium sulfate.
Th
After administering mag sulfate the dr ordered for the pts pulse, BP, and RR to be monitored
every 15 minutes and every hour after infusion, after administration there was no changes in pts
sh
status.
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
This study source was downloaded by 100000796901680 from CourseHero.com on 04-01-2021 17:09:04 GMT -05:00
https://www.coursehero.com/file/46535657/jones-DA/
