Clinical worksheet Brenda Patton PDF

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CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) Positive group B Strep test: The group B strep bacteria come and go naturally in people's bodies. If a pregnant woman has the bacteria in her body, she can pass it to her baby during labor and delivery. A group B strep infection happens when a baby is exposed to the bacteria while it's being born. In infants, illness caused by group B strep can be within six hours of birth (early onset) — or weeks or months after delivery (late-onset). Signs and symptoms might include: · Fever · Low body temperature · Difficulty feeding · Sluggishness, limpness, or weak muscle tone · Difficulty breathing · Irritability · Jitteriness · Seizures · Rash · Jaundice

Diagnostic Test (Reason for test and results)

Vaginal and rectal culture swab performed at 36-27 weeks of gestation

Patient Information

• • • • • • • •

18-year-old female G1P0 at 38 2/7 weeks of gestation PROM Aminisure test positive GBS test positive No significant medical history NKDA Current smoker (1/2 pack a day)

Anticipated Physical Findings • • • • • • • •

Elevated temp Occasional accelerations Positive Aminisure Positive GBS culture Elevated WBC Nause and vomiting Labor contractions Pain related to contractions

Interventions • • • • • •

•

Assess VS every 4 hours and as needed Assess temperature every hour due to PROM Assess characteristics of the amniotic fluid Assess maternal and fetal responses to labor Use nonpharmacological interventions to treat pain Determine, evaluate, and record intermittent auscultation, or revire and document EFM tracing og FHE every 30 minutes during active phase of the first stage of labor and at leart every 15 minutes during the active phase, second stage of labor. Monitor maternal neurologic status of signs of complication that would suggest she is preeclamptic.

vSim ISBAR ACTIVITY WORKSHEET INTRODUCTION

STUDENT My name is a Du te, student nurse with Keiser University, working on the labor and birthing unit.

Your name, position (RN), unit you are working on

SITUATION Patient’s name, age, specific reason for visit

BACKGROUND Patient’s primary diagnosis, date of admission, current orders for patient

Brenda Patton, 18-year-old Caucasian female, G1P0 at 38 2/7 weeks of gestation, admitted to the labor and birthing unit for labor assessment after PROM.

Patient reported that her water may have broken earlier this morning and believes she is now in labor. AmniSure was positive; Group B strep test was done at 36 weeks and was positive as well. Patient is receiving 5,000,000 IU of Penicillin IVPB and was educated on the benefits of it.

Current pertinent assessment data using headto toe approach, pertinent diagnostics, vital signs

Vaginal examination reveals 50% effacement of the cervix, 4 cm cervical dilation, and fetus at 2- station. Maternal VS- HR: 90. Pulse: Present. BP: 118/71 mmHg. RR: 20. Conscious state: Appropriate. SpO2: 98%. Temp: 99F (37C). Pain between contractions of. 2/10. Fetal VS- EFM:Baseline. FHR: 148. The patient wishes to have a natural birth without medication

RECOMMENDATION

Continue close monitoring of both Mather and fetus. Provide comfort measures that aligned with patient wishes.

ASSESSMENT

Any orders or recommendations you mayhave for this patient

PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION: Penicillin

CLASSIFICATION: Antibiotic

PROTOTYPE: Penicillin

SAFE DOSE OR DOSE RANGE, SAFE ROUTE 5,000,000 IU IV, followed by 2.5 – 3.0 million IU IV every 4 hours. The guidelines recommend a dosing range of 2.5 – 3.0 million IU to reach antibiotic levels in fetal circulation and amniotic fluid high enough for adequate prophylacis but low enough to avoid neurotoxicity. PURPOSE FOR TAKING THIS MEDICATION Prevent fetal contact and infection with group B strep, avoid complication following birth such as pneumonia, meningitis, sepsis, endocarditis and infection of the bloodstream.

PATIENT EDUCATION WHILE TAKING THIS MEDICATION Monitor nausea, vomiting, rash, GI upset, allergic reaction. Educate on the need for this medication

Clinical Worksheet Date: 10/28/2021 Patton Initials: B.P.

Student Name: Patricia Duarte Varela Diagnosis: PROM, positive GBS

HCP: Dr. Patricia Brown

Age: 18 M/F: Female

Isolation: Standard Fall Risk: Yes

Length of Stay: Unknown

Consults: None

Code Status: Full Code Allergies:NKDA

IV Type: Peripheral

Critical Labs: Positive GBS, Positive Location: Left forearm AmniSure

Transfer: N/A

Assigned vSim: Case 2: Brenda Other Services: EFM

Consults Needed: None Fluid/Rate: NS is indicated

Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: Patient’s water brake earlier this morning and she nows believes she is in labor

Health History/Comorbities (that relate to this hospitalization): Positive GBS

Shift Goals/ Patient Education Needs: 1. Deliver a healthy baby 2. Support patient’s wishes of a unmedicated birth 3. Educate the patient on GBS infection and how it might affect the fetus and why medication is needed 4. Prepare and education patient for labor and postpartum Path to Discharge: Patient is able to show she can accurately for for her newborn. She presents no signs or symptoms of infection or hemorrhafe. She is able to pass gas on her own. Baby has no signs or symptoms of BGS infection

Path to Death or Injury: Antibiotic not given: Fetus develops GBS infection which can cause meningitis, blood infection and many other complications

Alerts: What are you on alert for with this patient? (Signs & Symptoms)

Management of Care: What needs to be done for this Patient Today?

1. Infection of amniotic fluid

1.Treat GBS with Penicillin IV

2. Non-reasurring FHR

2. Provide non-pharmalogical pain relief

3.

4. Include mother and partner in care and decisions

Pain

5. Educate on what to expect during labor and postpartum What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?) 1. Temperature every hour 2. CBC with differential 3. Pain assessment

6. Administer acetaminophen for fever, if ordered 7. Administer medication for nausea, if ordered Priorities for Managing the Patient’s Care Today 1. Safe deliver 2.reduce risk of infection

List Complications may occur related to dx, procedure, comorbidities: 1. Fetus contracts GBS through birth

3.Monitor progression of labor and delivery 4. Provide education on expectant management to patient and family

2. Amniotic chorion infection What aspects of the patient care can be Delegated and who can do it? • Vital signs • I&O • Patient support What nursing or medical interventions may prevent the above Alert or complications? • Patient hygiene 3. NICU admission

1.Continuos monitoring of FHR 2. Administer Penicillin IV 3. C-section 4. Do not delay labor, if not occurring naturally induce...