Amelia sung documentation assignment PDF

Preview

Summary

amelia sung vsim documentation assignment answers...

Description

Maternity Case 5: Amelia Sung (Core) Documentation Assignments 1. Document Ms. Sung’s admission to the labor unit, including the plan of care and appropriate referrals. Ms. Snug is a 36-year-old Filipino woman G2P1 (L1) who was admitted 6 hours ago in active labor. At admission she was 4 cm dilated, 100% effaced, -1 station and fetus in vertex position. Epidural anesthesia was initiated at 0230 hours. Her membranes ruptures at 0330 hours. Due to her past history of shoulder dystocia a step stool was in the room and we monitored for turtle sign throughout labor. The NICU was informed of her labor and delivery and the charge nurse was also informed. The baby was delivered via normal vaginal delivery. 2. Document the essential events related to the time of birth, including the activities and interventions from the time of crowning to the complete expulsion of the fetus. After introducing myself to the patient and family member I wished my hands and identified the patient. The pt was in distress and mumbled responses. I completed VS and the mother expressed she felt a contraction coming. The head of the fetus started crowning at 0220. After assessing VS I checked the deep tendon reflexes as ordered and palpated the uterus for contractions. I then prepared the delivery table and assessed the pt’s IV site. I made sure the step stool was present in the room and I changed and weighed the bed pads. I calmed and supported the pt and family throughout the process. I also provided pt education. I instructed the pt to start pushing and encouraged them to push. I listened to the lung sounds of the pt with my stethoscope. I then prepared the bassinet and repositioned the client. I notified the NICU and charge nurse about the pt. The baby’s shoulders were delivered at 0811. I encouraged more pushing and the baby was born at 1335. 3. Using the situation-background-assessment-recommendation (SBAR) technique, document your communications with the provider when he or she arrives in Ms. Sung’s room after being called. Ms. Sung is a 36-year-old Filipino woman who was admitted for active labor. Her last delivery ended with shoulder dystocia because the baby was large. At admission she was 4 cm dilated, 100% effaced, -1 station and fetus in vertex position. Epidural anesthesia was initiated at 0230. Her membranes ruptured at 0330, fluid was clear, dilation was 6 cm and fetus was still at -1 station in vertex position. At 0008 I went in to assess the pt who was moaning from pain and unable to answer questions. She was tired form pushing and the descent of the fetal head was slow. The fetal HR has been stable with a baseline of 120/min. The baby’s head started to crown

From vSim for Nursing | Maternity. © Wolters Kluwer Health.

at 0220 and the baby was born at 1335. Her most recent vitals are: HR 97, BP 142/82 mmHg, RR 19, spo2 100%, temp 99 F. The baby was placed on the mother following delivery. I would continue to monitor the mother and baby’s VS for any concerning changes. I would promote skin to skin contact and watch for the baby’s first signs of voiding. 4. Document the fetal response to the second stage of labor. The fetal heart rate was at a stable 130 beats/min throughout the second stage of labor. At 0156 it raised to 138 beats/min and then went down to 134 beats/min at 0206. The fetal heart rate remained at 130 until 0532 when it dropped to 111 beats/min. At 0553 the fetal HR went up to 123 and as the pt started to push the fetal heart rate went to 129/min. At 0806the fetal heart rate dropped to 111 and after the shoulders were delivered the heart rate went to 123. For the remainder of the delivery the fetal HR was at a stable 130/min and then increased to 135/min at 1324 just before the baby was born. The baby was born at 1335.

From vSim for Nursing | Maternity. © Wolters Kluwer Health....