Maternity Case 07 Carla Hernandez Core DA PDF

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Maternity Case 7: Carla Hernandez (Core) Documentation Assignments 1. Document your initial assessment data for Carla Hernandez, including fetal heart rate activity (baseline fetal heart rate, long-term variability, accelerations, and decelerations) and maternal vital signs. a. Patient status - Heart rate: 89. Pulse: Present. Blood pressure: 136/81 mmHg. Respiration: 16. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 89. b. The electronic fetal monitor showed a non-reassuring drop in fetal heart rate. 2. Document the medication(s) that you administered. a. bolus of 500 mL of lactated Ringer solution IV, given over 10 minutes b. 0.25 mg of terbutaline subcutaneously 3. Document your situation-background-assessment-recommendation (SBAR) communication to Carla Hernandez’s provider and note any provider orders that were obtained during this simulation activity. a. S: Carla Hernandez is 32 years old female at 39 5/7 weeks gestation with umbilical cord prolapse b. B: G2P1, AROM before FHR dropped, currently have the patient in Trendelenburg position with a gloved hand releasing pressure on the cord. She was given 0.25mg of terbutaline subq c. A: Heart rate: 89. Pulse: Present. Blood pressure: 136/82 mmHg. Respiration: 15. Conscious state: Appropriate. SpO2: 100%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 104. d. R: I recommend we prepare for an emergency c-section 4. Document the time that the umbilical cord prolapsed during this simulation and the nursing interventions that were taken, including the timing. Note an evaluation of the effectiveness of these measures in resolving the problem identified, and the times that the provider was notified.  You arrived at the patient.  0:00 You introduced yourself.  0:05 You washed your hands.  0:10 Patient status - Heart rate: 89. Pulse: Present. Blood pressure: 136/81 mmHg. Respiration: 16. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 89.  0:15 The electronic fetal monitor showed a non-reassuring drop in fetal heart rate.  0:28 You identified the patient. If you are in doubt, it is always a good idea to repeat the identification.

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

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0:38 You asked if the patient was allergic to anything. She replied: No, I am not allergic to anything 0:55 You assisted the patient into Trendelenburg position. 0:57 You relieved pressure from the umbilical cord. This was indicated and the correct response to the patient condition. 1:09 Patient status - Heart rate: 91. Pulse: Present. Blood pressure: 140/83 mmHg. Respiration: 17. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C. EFM: Late deceleration. Fetal heart rate: 90. 1:11 You gave the patient 100% oxygen from a nonrebreathing mask. 1:13 You turned the oxygen on. 1:24 The electronic fetal monitor showed a late deceleration. 1:30 You assessed the patient IV. The site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact. This is correct. Assessing any IVs the patient has is always important. 1:39 You started a bolus of 500 mL of lactated Ringer solution IV, given over 10 minutes. It is important to use the basic rights of medication administration to ensure proper drug therapy. This was the correct response to the patient's condition. 1:55 You asked: How bad is the pain? She replied: Not too bad; its about a 2 between contractions 2:09 Patient status - Heart rate: 88. Pulse: Present. Blood pressure: 136/81 mmHg. Respiration: 15. Conscious state: Appropriate. SpO2: 98%. Temp: 37 C. EFM: Late deceleration. Fetal heart rate: 76. 2:13 You phoned the provider in order to discuss the patient. 2:30 Patient status - Heart rate: 87. Pulse: Present. Blood pressure: 139/82 mmHg. Respiration: 15. Conscious state: Appropriate. SpO2: 99%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 94. 3:26 You provided patient education. This is correct. It is important to provide patient educate to improve understanding of the patients medical condition and methodes and means to manage her condition. Effective communication and patient education increases patient motivation to comply. 3:30 Patient status - Heart rate: 87. Pulse: Present. Blood pressure: 138/83 mmHg. Respiration: 15. Conscious state: Appropriate. SpO2: 99%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 105. 3:54 You witnessed the patients signature on an informed consent. 4:30 Patient status - Heart rate: 87. Pulse: Present. Blood pressure: 134/81 mmHg. Respiration: 15. Conscious state: Appropriate. SpO2: 99%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 105. 5:01 You administered 0.25 mg of terbutaline subcutaneously. This was indicated by order. 5:18 You called the surgery unit. 5:30 Patient status - Heart rate: 87. Pulse: Present. Blood pressure: 137/82 mmHg. Respiration: 15. Conscious state: Appropriate. SpO2: 99%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 105. From vSim for Nursing | Maternity. © Wolters Kluwer Health.

5:51 Patient status - Heart rate: 88. Pulse: Present. Blood pressure: 136/82 mmHg. Respiration: 16. Conscious state: Appropriate. SpO2: 100%. Temp: 37 C. EFM: Late deceleration. Fetal heart rate: 105.  6:06 The electronic fetal monitor showed a late deceleration.  6:16 Patient status - Heart rate: 91. Pulse: Present. Blood pressure: 144/86 mmHg. Respiration: 17. Conscious state: Appropriate. SpO2: 100%. Temp: 37 C. EFM: Late deceleration. Fetal heart rate: 84.  6:21 You called the neonatal intensive care unit and asked for assistance.  6:29 Patient status - Heart rate: 90. Pulse: Present. Blood pressure: 140/84 mmHg. Respiration: 16. Conscious state: Appropriate. SpO2: 100%. Temp: 37 C. EFM: Late deceleration. Fetal heart rate: 63.  7:08 Patient status - Heart rate: 88. Pulse: Present. Blood pressure: 139/83 mmHg. Respiration: 15. Conscious state: Appropriate. SpO2: 100%. Temp: 37 C. EFM: Late deceleration. Fetal heart rate: 83.  7:18 Patient status - Heart rate: 88. Pulse: Present. Blood pressure: 140/83 mmHg. Respiration: 15. Conscious state: Appropriate. SpO2: 100%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 94.  7:37 You called the anesthesia care team and asked for assistance.  8:18 Patient status - Heart rate: 89. Pulse: Present. Blood pressure: 136/82 mmHg. Respiration: 15. Conscious state: Appropriate. SpO2: 100%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 104.  8:41 You transferred the patient to surgery. This was reasonable. 5. Document the fetal heart rate monitoring and any abnormalities. a. The heart monitor showed late declarations 6. Record the communication that was expressed to Carla Hernandez’s husband, Earl. a. The nurse told him, “delivery is needed because the blood flow through the umbilical cord is not getting enough oxygen to the baby. I understand that you are concerned about the well-being of your wife and baby. What are you feeling?” 7. Document how the health care team worked together during this simulation and state your recommendations for improvement. a. After calling the provider and obtaining orders to prep for an emergency c-section, I called anesthesia, NICU and surgery to notify them about the c-section. 

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