Olivia Jones v Sim - vSim CarePlan PDF

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CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) Preeclampsia is a pregnancy specific type of condition in which hypertension and proteinuria develop after 20 weeks of gestation in a woman who previously had neither condition. Preeclampsia is a progressive disorder with the placenta as the root cause. Therefore the disease begins to resolve after the placenta has been expelled.

DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) •CBC, CMP, AST, ALT •Ultrasound •Urinalysis •Non stress test •Biophysical profile

PATIENT INFORMATION

Olivia Jones is a 23 year old African American female, G1P0 at 36 weeks gestation. She has been diagnosed with severe preeclampsia and is admitted to the labor and delivery unit for assessment and surveillance.

ANTICIPATED PHYSICAL FINDINGS •Hypertension •Proteinuria •Thrombocytopenia •Impaired liver function •New on-set renal insufficiency •Pulmonary edema •Cerebral or visual disturbances

• Continuous monitoring of VS • Minimize outside stimuli • Put up seizure pads • Bed rest for patient • Careful monitoring of FHR and frequent ultrasounds • Magnesium sulfate to reduce risk of seizures • Monitor neurological status for visual disturbances, headaches, and deep tendon reflexes • Assess respiratory status for cough, SOB • Assess for N&V and epigastric pain

ANTICIPATED NURSING INTERVENTIONS

vSim ISBAR ACTIVITY

STUDENT

WORKSHEET INTRODUCTION

Catherine Espinosa, RN, Labor and Delivery 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

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

RECOMMENDATION Any orders or recommendations you mayhave for this patient

Olivia Jones is a 23-year-old African-American female has been diagnosed with severe preeclampsia and is admitted to the labor and delivery unit for assessment and surveillance.

Patient is diagnosed with severe preeclampsia, admitted on 2/13/2021. Current orders include NPO until serum lab result, result bed rest with ith bathroom privileges. Continuous BP monitoring q 1 hr for the first 2 hrs then q 4 hrs. Temp, HR, RR, q 1 hr. Breath sounds q 4 hrs, FHR/ UC monitoring, deep tendon reflexes q 1 hr, continuous pulse oximetry, obtain US, insert foley catheter.

BP: 172/102, HR: 104, Pulse is present, RR: 22, Temp: 99, FHR: 150, +4 SPO2: 89%, 89% no obvious airway obstruction, obstruction skin is Deep Tendon +4, cool and sweaty, crackles in both bases of the lungs

Minimizing outside stimuli (light, noise, visitors) and putting up sei ure pads seizure pads, O2 non rebreather 10L 10L, continuous BP and pulse oximetry monitoring

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

MEDICATION: Magnesium Sulfate

CLASSIFICATION: Therapeutic: mineral and electrolyte replacements/supplements; Pharmacologic: minerals/electrolytes

PROTOTYPE: Magnesium Hydroxide

SAFE DOSE OR DOSE RANGE, SAFE ROUTE Preeclampsia, Eclampsia: Adult: IM/IV 4 g in 250 mL D5W infused slowly, followed by 4–5 g IM in alternate buttocks q4h PURPOSE FOR TAKING THIS MEDICATION Replacement in deficiency states. Resolution of eclampsia.

PATIENT EDUCATION WHILE TAKING THIS MEDICATION • Explain use and administration of drug to patient and family. • Drink sufficient water during the day when drug is administered orally to prevent net loss of body water. • Recommended daily allowances of magnesium are obtained in a normal diet. Rich sources are whole-grain cereals, legumes, nuts, meats, seafood, milk, most green leafy vegetables, and bananas. • Do not breast feed while taking this drug without consulting physician.

Clinical Worksheet Date: 2/13/2021 Init ials:

Diagnosis: Severe preeclampsia

O.J.

Length

Student Name: Catherine Espinosa HCP: Dr. Sara Anderson

Isolation: Standard precautions

Consults: N/A Age :

Fall Risk: Yes of Stay: Transfer: No

23 N/A M/ F:

Allergies

F Code Status: Unknown

: No

Assigned vSim: Olivia Jones

IV Type: Lactated Critical Labs: -Platelets Ringers -RBC -MCH -MCHC Location: Forearm -Creatinine -BUN -ALT Fluid/Rate: -AST -LDH LR 125ml/hr continuous -Triglycerides infusion -Creatinine clearance Magnesium Sulfate 6g in 100 mL sterile water over 30 min

Other Services: Insertion of foley catheter Ultrasound Consults Needed: N/A

known

allergies

Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: Olivia Jones was admitted to the hospital due to severe preeclampsia. Routine prenatal visit at 30 weeks shows elevated BP 146/92 mmHg, proteinuria, and developing mild preeclampsia. She has been on bed rest at home until prenatal visit today with increasing symptoms, resulting in admission. Health History/Comorbities (that relate to this hospitalization): •Ms. Jones has gained 3 pounds since prenatal visit 1 week ago. Protein dipstick is +4, negative ketones, negative glucose, +2 dependent edema, and facial puffiness. •Headache unresolved with acetaminophen. Ms. Jones presents with nausea and fatigue and complaining of epigastric pain visual changes, and chest tightness. The fetus is active; however, patient states that it is a bit quieter than normal. There is a possibility of premature rupture of membranes Shift Goals/ Patient Education Needs: 1. 1.) Provide Patient education and teaching about diagnosis and treatment. Inform patient that she must be on bed rest with minimal stimulation 2.) Patient will maintain an SpO2 reading >92% and BP 92% and BP...