Richardson, Anna Postpartum Urinary Retention O Taran PDF

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Summary

EAQ study...

Description

Assignment: Richardson, Anna: Postpartum Uri... Richardson, Ann...

MRN: 2471206

Room: 373

Health Care Provider: G Brown, MD

Sex: F

Weight: 180 lbs

Code Status: 00

Isolation: 00

Food Allergies: 00

Age: 34 Y

Height: 5' 5"

Alerts: 00

Drug Allergies: 01

Env. Allergies: 00

Diet: 00

Hospital Floor: Women's Health

Student: Olena Taran Assignment: Richardson, Anna: Postpartum Urinary RetentionSubmitted: 01/27/2021 21:26

Case Study Assignment Grading Case Study Scenario No:

8502552

Student Level:

Basic

Title:

Richardson, Anna: Postpartum Urinary

No. of Phases:

4

Retention

Objectives:

1. The student will provide

Short Description: Keywords:

Description:

Elsevier : WOMEN'S HEALTH : Level 1, 65

individualized, patient-centered care by

minutes

documenting postpartum patient

Postpartum vaginal delivery, Rubella

assessment findings, nursing

vaccination, Postpartum urinary retention,

interventions, and postpartum maternal

Perineal laceration, Basic

and infant patient education.2. The

Anna Richardson is a 34-year -old gravida 1

student will identify factors that influence quality of care by recognizing

para 1 patient who had a vacuum-assisted

deviations from normal assessment

vaginal delivery last night. One hour after

findings and possible reasons for these

delivery she experienced a postpartum

findings. 3. The student will function as

hemorrhage. She is stable and has been

an effective member of the health care

doing well on the postpartum unit. The student will enter data into Mrs. Richardson’s

team by demonstrating knowledge of the physiology of postpartum urinary

electronic medical record which will include

retention and identifying nursing interventions for postpartum urinary

patient assessment, verification of physician orders, medication administration, and

retention. 4. The student will apply best

documentation of patient teaching.

available standards of care by identifying nursing interventions for postpartum perineal care. 5. The student will function as an effective member of the health care team by demonstrating knowledge of rubella and the rubella vaccination. Course:

Maternity and Womens Health

Topic:

Postpartum Urinary Retention

Patient Profile EHR Details

Patient Details

MRN Number:

8502552

First Name:

Anna

Room Number:

373

Last Name:

Richardson

Primary Diagnosis:

Pregnancy, term

Gender:

F

Age:

34 Years

Secondary Diagnosis:

Postpartum maternal care

Length of stay (Days):

7

Admission Day:

Sun

Admission Time:

06:00

Provider Details First Name:

Greg

Last Name:

Brown

Credentials:

MD

Phase Information Phase

Objective

Information

#

Start Time / Duration

0

You are the postpartum nurse assuming the care of Anna Richardson, a 34-year -old patient who had a vacuum-assisted

Mrs. Richardson is a 34-year -old gravida 1 para 1 female who had a vacuumassisted vaginal delivery of a healthy, term female infant weighing 9 pounds,

Sun 06:00 1559

vaginal delivery last night at 1730. She had a postpartum

3 ounces at 1730 on Sunday. Her epidural has been removed. Her husband,

minutes

hemorrhage one hour after delivery but has since stabilized and

Robert, is here and is supportive. She has a second degree perineal

was transferred to the postpartum floor. Both mom and baby’s

laceration with repair

vital signs have been stable. 1

1. The student will document a postpartum system assessment

NOTE TO STUDENT:

Mon 08:00

accurately and thoroughly. 2. The student will document vital signs accurately and

You have 60 minutes to complete this phase. Press the Pause button when not actively charting.

60 minutes

completely.

To exit SimChart, press the Logout button in the upper-right corner of the

3. The student will document the IV site assessment and a

screen.

change in IV status accurately. You are the day shift nurse assuming care of Anna Richardson. You enter Mrs. Richardson’s room and she states that she still has pain despite taking ibuprofen almost an hour ago. She also states that it seems like her vaginal bleeding has increased. Baby girl Richardson is rooming in. Anna reports no signs of depression or sadness and is breastfeeding on demand. Fundus is firm, deviated to right of midline, 2 cm above umbilicus. Lochia is present; rubra, moderate You assess her perineum. The laceration edges are well approximated.The site is red with moderate swelling and bruising present. There are no hemorrhoids present at this time. Apical pulse is regular, no murmur. No cardiac problems noted. Pedal pulses are 2 bilateral and regular. No edema. Anna's respirations are even and effortless. No problems identified and all fields are clear. She is calm and alert; oriented to person, place, and time. Anna is in pain, which she reports as 5 out of 10 and describes as constant abdominal cramping. Hospital and allergy bracelets are in place and standard precautions are in effect. [STUDENT ACTION: Document the assessment in System Assessments and Wounds.] Vital Signs: Temperature: 98.5 degrees Fahrenheit, oral... Heart Rate: 94, radial... Respiratory Rate: 18 Blood Pressure: 128/78 mmHg left arm, sitting... [STUDENT ACTION: Document the vital signs.] You assess the IV site and find no redness or swelling present. Transparent dressing is clean and dry. You change the IV from lactated Ringer’s to a saline lock and flush it with 10cc normal saline. [STUDENT ACTION: Document the IV site assessment and IV change.] When you have completed the above tasks, click Complete this Phase. 2

1. The student will transcribe and verify a provider order.

NOTE TO STUDENT:

Mon 09:10

2. The student will document a straight catheterization and

You have 60 minutes to complete this phase.

60 minutes

perineal care.

Press the Pause button when not actively charting.

3. The student will document patient teaching of perineal care.

To exit SimChart, press the Logout button in the upper-right corner of the

4. The student will document a pain assessment and the administration of pain medication accurately.

screen. Anna Richardson has tried several non-invasive techniques but is still unable to empty her bladder. You notify the provider and he writes an order to perform a straight catheterization now, and insert an indwelling catheter if she is unable to void greater than 150 mL in a single void within the next 6 hours. [STUDENT ACTION: Verify and enter this order.] You perform a straight catheterization at and obtain 750 mL of clear yellow urine. [STUDENT ACTION: Chart the catheterization and the result.] As you provide perineal care, you teach Anna Richardson about how she should care for her perineal laceration. She verbalizes understanding of your instructions. [STUDENT ACTION: Document the appropriate perineal care and your patient teaching.] Mrs. Richardson states that her pain has increased and is a “6” on a 0-10

scale. She describes the pain as constant abdominal cramping. [STUDENT ACTION: Chart this pain assessment.] STUDENT ACTION: Select and administer an appropriate pain medication for Anna on the MAR.] When you have completed the above tasks, click Complete this Phase. 3

1. The student will review provider orders and prenatal record.

NOTE TO STUDENT:

Tue 08:30

2. The student will document the administration of medication

You have 60 minutes to complete this phase.

60 minutes

accurately.

Press the Pause button when not actively charting.

3. The student will review provider orders to verify the necessity

To exit SimChart, press the Logout button in the upper-right corner of the

of a postpartum rubella vaccine.

screen.

4. The student will document administration of vaccine on the MAR accurately.

You are Anna Richardson’ s nurse for the day shift again. The night nurse has reported that Mrs. Richardson is now voiding independently and her pain has been well controlled with ibuprofen 600 mg every 6 hours. Her last dose was at 0745. The baby is doing well and is breastfeeding independently. The provider has made his morning rounds and signed Anna Richardson’s discharge orders. [STUDENT ACTION: Review the provider orders.] You administer Mrs. Richardson’s morning medications at 0815. [STUDENT ACTION: Chart the morning medication administrations.] You notice that the provider has ordered a rubella vaccine prior to Mrs. Richardson’s discharge. [STUDENT ACTION: Review the patient's clinic History & Physical record to verify that the vaccination is indicated.] If it is indicated: Anna Richardson agrees to receive this immunization. You administer the vaccine. [STUDENT ACTION: Chart on the MAR that the immunization was administered and document the injection site in a location of your choosing.] If it is not indicated: Leave the MAR blank. When you have completed the above tasks, click Complete this Phase.

4

1. The student will document patient teaching accurately and

NOTE TO STUDENT:

Tue 11:45

thoroughly.

You have 60 minutes to complete this phase.

60 minutes

2. The student will complete patient discharge and discharge

Press the Pause button when not actively charting.

summary forms accurately. 3. The student will identify areas in which a patient needs

To exit SimChart, press the Logout button in the upper-right corner of the screen.

education regarding infant and maternal care. Anna Richardson will soon be discharged. Her husband will be arriving in one hour to pick her up to bring her back to their home. You notice that Mrs. Richardson has not received all of her postpartum teaching. You review the patient teaching record and select 4 topics related to maternal care and 4 topics related to newborn care that have not already been covered to discuss with Mrs. Richardson. Mrs. Richardson verbalized understanding of all materials covered. [STUDENT ACTION: Chart the teaching that was done in the patient education record, and Mrs. Richardson’ s verbal understanding of the topics.] You complete the discharge planning and discharge summary forms. Anna Richardson does not have any tentative needs before discharge, she does not need any assistance from outside facilities, and she does not have any challenges identified. [STUDENT ACTION: Complete the discharge planning and summary forms and highlight areas of teaching have been covered with Mrs. Richardson during her stay in Care Instructions.] When you have completed the above tasks, you may Complete and Submit the assignment.

Student Documentation Expand All

Collapse All

Phase 1 Mon 08:00 Expected Charting

Student Charting

Vital Signs Created Date:

Mon | 08:00

Created By:

O Taran Mon | 08:35

Temperature:

98.5

Site:

Oral

Temperature:

98.5

Site:

Oral

Pulse:

94

Site:

Radial

Pulse:

94

Site:

Radial

Respiration:

18

Respiration:

18

BP Systolic:

128

Site:

Left arm

BP Systolic:

128

Site:

Left arm

BP Diastolic:

78

Position:

Sitting

BP Diastolic:

78

Position:

Sitting

System Assessments Created Date:

Mon | 08:00

Created By:

O Taran Mon | 08:28

Patient Charting Summary:

System Assessments Mon 08:00

Patient Charting Summary:

System Assessments Mon 08:28

Chart Time:

Mon | 08:00

Chart Time:

Mon | 08:28

Obstetric Assessment

Postpartum Assessment

Obstetric Assessment

Postpartum

l

No assessment required at this time

Rooming in status:

Postpartum Assessment

l

No

l

Yes

l

Firm

l

Deviated

History of Falling l

Continuous

l

No

Behavioral Signs of depression or sadness:

Continuous

Morse Fall Scale

Postpartum Rooming in status:

l

l

No=0

Postpartum Assessment Behavioral Signs of depression or sadness:

Breasts Breastfeeding:

l

Yes

Morse Fall Scale Secondary Diagnosis

l

Breastfeeding on demand

l

Fundus Fundus characteristics:

No=0

Postpartum Assessment l

Firm

Breasts Breastfeeding:

Position:

l

Deviated

Morse Fall Scale l

Right of midline

Ambulatory Aid l

Height:

l

2 cm above umbilicus

Postpartum Assessment

Lochia Color:

None/Bedrest/Nurse Assist=0

l

Rubra

Fundus Fundus characteristics:

Quantity:

l

Moderate

Morse Fall Scale IV or IV Access

Perineum Edema:

l

Moderate

Incision or laceration:

l

Edges well-approximated

l

Yes=20

Postpartum Assessment Fundus

Color:

l l

Red Bruising

Position:

Morse Fall Scale Rectum Hemorrhoids:

Gait l

None

Cardiovascular Assessment

Normal/Bedrest/Wheelchair=0

Postpartum Assessment

Pulses Apical:

l

Fundus l

Regular

l

Right of midline

Murmur noted:

l

No

Morse Fall Scale Mental Status

Peripheral Pulse

l

Left Posterior Tibial Pulse:

l

2+ Expected

Pulse:

l

Regular

Oriented to Own Ability=0

Postpartum Assessment Fundus Height: Right Posterior Tibial Pulse:

l

2+ Expected

Pulse:

l

Regular

l

2 cm above umbilicus

l

20

l

Rubra

Morse Fall Scale Total Fall Risk Score Risk Score:

Left Dorsalis Pedis Pulse:

l

2+ Expected

Pulse:

l

Regular

Postpartum Assessment

Right Dorsalis Pedis Pulse:

l

2+ Expected

Color:

Pulse:

l

Regular

Morse Fall Scale

Lochia

Fall Risk Score and Preventative Measures Implemented Tissue Perfusion Peripheral vascular, general:

Fall Risk Level: l

l

Low Risk

l

Moderate

Warm extremities

Postpartum Assessment Edema l

Lochia

No edema noted

Quantity:

Morse Fall Scale

Cardiac Assessment l

No cardiac problems noted

Fall Risk Score and Preventative Measures Implemented Fall Risk Measures:

l

Implement Low Risk Fall Pre

Respiratory Assessment

vention Interventions:All admitte

Respiratory Pattern

d patients, orient to surroundings, pa tient and family education about risk,

l l

Even Effortless

toileting program, bed in low positio n, evaluate medication response, per sonal items in reach, night light as ap propriate, nonskid footware, decrea

Upper Right Anterior Auscultation:

l

Postpartum Assessment

Upper Left Anterior Auscultation:

l

Clear

Left Lateral Auscultation:

se room clutter.

Clear

l

Perineum Edema:

l

Moderate

Incision or laceration:

l

Edges well-approximated

Clear Color:

l

Red

l

Bruising

l

None

Apical:

l

Irregular

Murmur noted:

l

No

Left Dorsalis Pedis Pulse:

l

2+ Expected

Pulse:

l

Regular

Right Dorsalis Pedis Pulse:

l

2+ Expected

Right Lateral Auscultation:

l

Clear

Rectum Upper Left Posterior Auscultation:

Hemorrhoids: l

Clear

Cardiovascular Assessment Upper Right Posterior Auscultation:

Pulses l

Clear

l

Clear

Lower Left Posterior Auscultation:

Peripheral Pulse Lower Right Posterior Auscultation:

l

Clear

Neurological Assessment Level of Consciousness/Orientation l

Oriented to person, place, time, and situation

Pulse:

l

Regular

l

Room Air

Quality of Pain:

l

Cramping

More information of Quality of Pain:

l

Emotional State l

Edema

Calm

l

No edema noted

Pain Assessment Cardiac Assessment

Do You Have Pain Now? l

l

Yes

Respiratory Assessment

Location of Pain l

Respiratory Pattern

abdominal

Frequency of Pain l

No cardiac problems noted

l

Even

l

Effortless

Constant

Oxygenation Oxygen delivery system:

Intensity of Pain l

5

Pain Assessment Quality of Pain: