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.
[Date]
, 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.
[Date]
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.
[Date]
, 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.
[Date]
