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Maternity Case 1 Olivia Jones Documentation
Vsim Maternal Case 1 Documentation for patient Olivia Jones
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University of Florida
Academic year: 2022/2023
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Maternity Case 1: Olivia Jones
Documentation Assignments
- Document the data from your focused antepartum assessment of both Ms. Jones and the fetus. Patient Information: Olivia Jones, 23 years old, Female, African American Antepartum Information: 36 weeks gestation, G1P Dx: Severe, Progressive Preeclampsia S/S: HTN, Weight gain, Headache, Nausea, Epigastric pain, Proteinuria, Blurry/spotty vision
- 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. S: The patient’s name is Olivia Jones, a woman currently at 36 weeks gestation. She has been diagnosed with severe preeclampsia and has been admitted to the labor and delivery unit surveillance with complaints of headache, epigastric pain, and nausea. Her pain has not resolved after taking acetaminophen. Additionally, she has reported blurry vision along with spots, and a tightness in her chest. B: Pt. name = Olivia Jones; Age = 23; Ethnicity = African-American; Hx = 36 wks gestation A: She has been assessed to have come seeking medical attention for complications related to her preeclampsia. She weights 110 kg. Vital signs are as follows: BP = 146/92, Temperature = 99° F, HR = 110 bpm, RR = 12 breaths/min. Neurological assessment reflects 2+ DTR, Skin assessment reflects +1 pitting edema on lower extremities. Respiratory assessment reflects clear lungs sounds. To treat Ms. Jones, patient education was initiated. VS were continuously monitored and the EFM was attached, reflecting a Fetal HR of 138 bpm, and fetal movement was positive. 2L of Oxygen has been administered by nonrebreather. Medications given are Magnesium sulfate and Promethazine.
- Document the teaching you would provide to the patient and her support person prior to administering magnesium sulfate. Fully explain, in layman’s terms, all procedures, equipment, meds, and potential side effects. Allow for questions to be asked and answered. Promote expression of anxiety surrounding the premature birth. Keep patient and family up to date on any changes in status of mom or baby Begin patient education to increase knowledge and skills concerning preterm labor. Patient education is individualized by may include the following: o Medication administration, timing and adverse reactions o Palpation of uterus and timing of contrations o Importance of proper rest and nutrition, along with staying hydrated o S/S representing preterm labor and importance of immediately reporting them
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
- Document the administration of the magnesium sulfate bolus and the initiation of the magnesium sulfate infusion. Relative maternal and fetal assessments completed Patient education regarding the application of magnesium sulfate Magnesium sulfate measured in g/mL and administered in mL/hr Notification of provider, including indication and reaction
- Document your reassessment of the patient’s status after administering magnesium sulfate. Completed assessment HR and BP every 15 minutes for first hour of infusion and following any dosage increase every 30 minutes during the second hour of magnesium sulfate therapy. Additionally assessed HR and BP a minimum of once per hour during maintenancy therapy. The patient’s pulse and BP diminished to higher levels, but within normal range.
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
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Maternity Case 1 Olivia Jones Documentation
Course: Care Manage Children (NUR 3355)
University: University of Florida
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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.
Patient Information: Olivia Jones, 23 years old, Female, African American
Antepartum Information: 36 weeks gestation, G1P0
Dx: Severe, Progressive Preeclampsia
S/S: HTN, Weight gain, Headache, Nausea, Epigastric pain, Proteinuria, Blurry/spotty
vision
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.
S: The patient’s name is Olivia Jones, a woman currently at 36 weeks gestation. She has
been diagnosed with severe preeclampsia and has been admitted to the labor and
delivery unit surveillance with complaints of headache, epigastric pain, and nausea. Her
pain has not resolved after taking acetaminophen. Additionally, she has reported blurry
vision along with spots, and a tightness in her chest.
B: Pt. name = Olivia Jones; Age = 23; Ethnicity = African-American; Hx = 36 wks gestation
A: She has been assessed to have come seeking medical attention for complications
related to her preeclampsia. She weights 110 kg. Vital signs are as follows: BP = 146/92,
Temperature = 99° F, HR = 110 bpm, RR = 12 breaths/min. Neurological assessment
reflects 2+ DTR, Skin assessment reflects +1 pitting edema on lower extremities.
Respiratory assessment reflects clear lungs sounds. To treat Ms. Jones, patient education
was initiated. VS were continuously monitored and the EFM was attached, reflecting a
Fetal HR of 138 bpm, and fetal movement was positive. 2L of Oxygen has been
administered by nonrebreather. Medications given are Magnesium sulfate and
Promethazine.
3. Document the teaching you would provide to the patient and her support person prior to
administering magnesium sulfate.
Fully explain, in layman’s terms, all procedures, equipment, meds, and potential side
effects. Allow for questions to be asked and answered.
Promote expression of anxiety surrounding the premature birth.
Keep patient and family up to date on any changes in status of mom or baby
Begin patient education to increase knowledge and skills concerning preterm labor.
Patient education is individualized by may include the following:
oMedication administration, timing and adverse reactions
oPalpation of uterus and timing of contrations
oImportance of proper rest and nutrition, along with staying hydrated
oS/S representing preterm labor and importance of immediately reporting them
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
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