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Olivia jones SBAR
Course: Common Health Deviations 2 (VN235)
7 Documents
Students shared 7 documents in this course
University: Long Beach City College
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Maternity Case 1: Olivia Jones
Documentation Assignments
1. Document the data from your focused antepartum assessment of both Ms. Jones and the
fetus.
- Took vitals: BP:171/102 HR:114 R: 22 SPO2: 90% T:99F FHR:157 Pain: upper center of
stomach under right breast 4/10.
- Administered oxygen via non- rebreathing mask 10L/ doctors order.
- Pt was experiencing nausea / administered promethazine 25mg orally.
- Assessed skin/ was cool and sweaty / presented moderate to severe pitting edema +3.
- Performed vaginal exam, cervix 0 cm open / palpated uterus for contractions, no
contractions noted and the fetal movement was present.
- Inserted Urinary catheter to monitor I&O/ doctors order
- Requested Ultrasound/ doctors order
- Assessed visual changes- stated “ vision is blurred and i can see some spots”
- Placed seizure pads
- called provider and they placed an order for magnesium sulfate in sterile water (6g in
100mL) at 200mL/hr / administered medication.
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.
-Pt Olivia Jones 23yo AA female, G1P0 currently 36wks of gestation. She was diagnosed and
admitted with severe preeclampsia currently monitoring and assessing her symptoms.
Last vitals taken were BP: 169/100 HR:104 R:22 SPO2: 99 on 10L of oxygen via non-
rebreather mask per order FHR: 157, fetal movement during abdominal assessment. Pt
presenting blurred vision, nausea and epigastric pain 4/10 and refused pain medication.
Administered promethazine 25mg for nausea and magnesium sulfate. pt currently on bed
rest with bathroom privileges and NPO. Ultrasound and labs were taken.
3. Document the teaching you would provide to the patient and her support person prior to
administering magnesium sulfate.
- explain the use of magnesium sulfate (educate on the reasons its being used, to decrease
the chance of seizure)
- Mention the importance of keeping up with labs to keep track of magnesium levels.
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
