Brenda Documentation PDF

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Maternity Case 2: Brenda Patton Documentation Assignments 1. Document your initial assessment data of Ms. Patton, including uterine activity (frequency and duration), fetal heart rate (FHR) activity (baseline FHR, long-term variability, accelerations, and decelerations), vaginal discharge, and maternal vital signs. The patient cervix was effaced 65% and 4cm open. Vertex fetal presentation at -2 station. The amnioyic membrane is ruptured. The uterus is soft between contractions. She is having regular contractions with moderate intesntiy. Upon vaginal exam there was no vaginal discharge The contractions are approximately 4 min apart and lasting 50sec. Patient BP was 118/72, RR 19, temp is 99deg F (37 C), HR is 90 per min. The Fetus info is as followed : early deceleration FHR 140, occasional acceleration is 149. 2. Document the medication(s) that you administered. Penicillin 5,000,000 units administered through IV piggyback. 3. Document Ms. Patton’s pain during labor (severity during contractions, location, quality, interventions taken, and response to interventions) and the measures that were taken to promote her desire for a natural birth. She is having regular contractions with moderate intesntiy. The contractions are approximately 4 min apart and lasting 50sec. The pain level indicated by the patient is a 2 between contractions. There was no need for any pain suppressant/epidural etc. Her pain was located in her back and lower abdomen. Following the proper steps to make her to make her feel comfortable with movement and postioning, monitoring her vital signs, keeping patient relaxed, breathing correctly, and giving her massage this allowed for the patient to maintain her desire for a natural birth. 4. Document your handoff report in the situation-background-assessment-recommendation (SBAR) format to communicate what further care Ms. Patton needs. (s) Patient is a 18yr old female Caucasian, G1PO at 38 2/7 weeks of gestation in active labor. Patient states that her water may have broken early this morning. Amnisure was positive. Vaginal exam reveals 50% effacement of cervix, cervical dilation is 4cm and fetus at -2 station. Patient also tested positive for group B strep vaginorectal culture that was taken at 36 weeks. (b) Firt time mother no medication, healthy female, her contractions are approximately 4 min apart and lasting 50sec. Patient BP was 118/72, RR 19, temp is 99deg F (37 C), HR is 90 per min O2 97%. The Fetus info is as followed : early deceleration FHR 140, occasional acceleration is 149.

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

(a) Patient is in active labor all indications leading toward a natural child birth. Fetus is in a longitudinal lie, in vertex presentation. (r) Make her feel comfortable with movement and postioning, monitoring her vital signs, keeping patient relaxed, breathing correctly, and providing emotional support allowing for the patient to maintain her desire for a natural birth. Monitor for adverse side effects from penicillin antibiotic infusion. 5. Document the informal patient education that you provided to Ms. Patton during this scenario regarding group B streptococcus and the patient’s response to this teaching session. Communicated to the patient that group B strep is a bacterial infection that could possible harm the baby if not treated with antibiotics. The antibiotics will not harm the baby. She was comfortable with the information and the antibiotics were administered.

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