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Olivia Jones Documentation
Pediatric Nursing (NUR 41200)
Purdue University
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Maternity Case 1: Olivia Jones
Documentaion Assignments
- Document the data from your focused antepartum assessment of both Ms. Jones and the fetus.
Paient status - Heart rate: 111. Pulse: Present. Blood pressure: 170/101 mmHg. Respiraion: 22. Conscious state: Appropriate. SpO2: 92%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 153. Pain 4/10. Headache across forehead. C/o epigastric pain. C/o visual disturbances, blurred vision with some spots. There is normal elasicity of the skin. Her skin is cool and she is very sweaty. RR 22. Chest moving equally. Lungs sounds crackles at both bases, heart sounds clear without murmur. The deep tendon relexes were very brisk, hyperrelexive, and with clonus. Graded to +4. The fetus is in longitudinal lie, in vertex presentaion.
- Write the situaion-background-assessment-recommendaion (SBAR) communicaions you would use to update the provider on Ms. Jones’s status at the ime of her admission.
S: Olivia Jones is a 23-year-old African-American female, G1P0 at 36 weeks of gestaion. She has been diagnosed with severe preeclampsia and is admited to the labor and delivery unit for assessment and surveillance. B : 30 weeks with elevated blood pressure at 146/92 mm Hg, proteinuria, and developing mild preeclampsia. She has been on bed rest at home unil prenatal visit today with increasing symptoms, resuling in admission. She has gained 3 pounds since prenatal visit 1 week ago. Protein dipsick is +4, negaive ketones, negaive glucose, +2 dependent edema, and facial puiness. A: Heart rate: 111. Pulse: Present. Blood pressure: 170/101 mmHg. Respiraion: 22. Conscious state: Appropriate. SpO2: 92%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 153. Pain 4/10. Headache across forehead. C/o epigastric pain. C/o visual disturbances, blurred vision with some spots. There is normal elasicity of the skin. Her skin is cool and she is very sweaty. RR 22. Chest moving equally. Lungs sounds crackles at both bases, heart sounds clear without murmur. The deep tendon relexes were very brisk, hyperrelexive, and with clonus. Graded to +4. R: Keep communicaion open with interprofessional team.
- Document the teaching you would provide to the paient and her support person prior to administering magnesium sulfate.
Magnesium sulfate is administered to prevent seizures. Inform the nurse if the paient feels faint, is having diiculty breathing, numbness around her mouth, muscle ightness and contracions. The paient’s vital signs will be check Q5-15min
- Document the administraion of the magnesium sulfate bolus and the iniiaion of the magnesium sulfate infusion.
You started infusing magnesium sulphate in sterile water (6g in 100 mL) at 200 mL/hr. It is important to use the basic rights of medicaion administraion to ensure proper drug therapy. This was indicated by order. The dose was veriied by a second nurse.
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
- Document your reassessment of the paient’s status ater administering magnesium sulfate.
Paient no longer complains of dizziness. C/o headache, pain 4/10 Vital signs, Paient status - Heart rate: 101. Pulse: Present. Blood pressure: 165/99 mmHg. Respiraion: 22. Conscious state: Appropriate. SpO2: 98%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 150.
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
Olivia Jones Documentation
Course: Pediatric Nursing (NUR 41200)
University: Purdue University
