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Situation

Olivia Jones, 23- year- old, African- American female, G1PO 36 weeks of gestation. Has

epigastric pain, visual changes, and chest tightness. Has a headache that is unresolved with

acetaminophen

Background

Patient diagnosed with severe preeclampsia, protein found in urine, has gained three pounds

since prenatal visit. Presented with edema +2 and facial puffiness.

Assessment

Patient has a temp of 99F, BP of 170/102 R22, SpO2 90 and heart rate of 115. The patient

reports of feeling nauseated, headache and visual changes.

Recommendation

Patient’s environment remains in seizure precaution. Suction remains at bedside. Bed set to the

lowest setting, side rails up and padded. Patients receive continuous fluids, Vitals monitored for

mother and fetal status done the same. Patient should lay in a side line position and possibly

receive Magnesium Sulfate

Olivia Jones SBAR - lab work