VSIM Brenda Patton Maternity Case Assignment

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. - Ms. Patton’s vital signs: Heart rate: 89. Pulse: Present. Blood pressure: 120/71 mmHg. Respiration: 19. Conscious state: Appropriate. SpO2: 98%. Temp: 37 C. EFM: Occasional acceleration. Fetal heart rate: 140. The uterus tone was soft between contractions. Regular contractions with moderate intensity had started. Contractions were approximately 4 minutes apart and lasting 50 seconds. 2. Document the medication(s) that you administered. - I started a piggyback infusion of 5000000 IU of penicillin IV. Using the basic rights of medication administration to ensure proper drug therapy. 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. - Patient stated she had some pain. When I asked her how bad it was she responded with “Not too bad, its about a 2 between contractions”. I asked her where it hurt and she responded with everywhere. I offered Ms Patton something for the pain and she states she was okay. Comfort measure were given. 4. Document your handoff report in the situation-background-assessmentrecommendation (SBAR) format to communicate what further care Ms. Patton needs. - - Situation: Brenda Patton is an 18-year-old Caucasian female, G1P0 at 38 2/7 weeks of gestation admitted to the labor and birthing unit for labor assessment. Background: The lab report indicates that the patient's group B strep vaginorectal culture taken at 36 weeks was positive. The patient wishes to have a natural birth without medication. Assessment: Heart rate: 89. Pulse: Present. Blood pressure: 117/70 mmHg. Respiration: 20. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 141. Vaginal exam reveals 50% effacement of cervix, cervical dilation 4 cm, and fetus at -2 station. Contractions were approximately 4 minutes apart and lasting 50 seconds. Recommendation: Administered 5million unit of penicillin IVPB, continue to administer antibiotic per providers order, provide support especially through contractions. Patient requested a natural birth, assist her in nonpharmacologic pain management. Assess q1h. 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. - Group B streptococcal (GBS) disease continues to be the leading infectious cause of morbidity and mortality among infants in the United States. The primary risk for infant GBS disease is maternal intrapartum GBS colonization; thus, screening for GBS during the antepartal period is critical, as is treatment prophylactically during the intrapartum period. Effective and recommended drugs are penicillin, ampicillin, and firstgeneration cephalosporins. It is important to provide patient educate to improve understanding of the patient’s medical condition and methodes and means to manage her condition. Effective communication and patient education increases patient motivation to comply and so Ms Patton agreed to allow us to give Penicillin.