University:
Rasmussen University
Course:
NUR 2633| Maternal Child Health Nursing
Academic year:

2023
Views:

90

Pages:

2
Author:

Karsyn Lester

Lily is a 16 year old G1, twin gestation who presents to labor and delivery at 35 weeks gestation with reports of “bad headaches over the past week, now constant” that are not relieved by Tylenol. She states that she has had blacked out spots in her vision today. Her mother accompanies her and reports that she has “not seemed like herself”. She reports active fetal movement and denies contractions, cramping, or abdominal pain; denies leaking fluid or vaginal bleeding. Upon assessment you find that she has 2+ edema to the distal upper extremities, 3-4+ pitting pedal edema and 2-3+ pretibial edema in the LE bilaterally. Breath sounds are clear. Initial BP is 172/99. Urine dip reflect 3+ protein. DTRs are brisk: 4+; 1 beat of clonus is noted. Initial monitoring produces a reactive NSTs for both fetuses. She denies past medical problems, surgical history, and reports an allergy to latex (S) Situation: What is the situation you are calling about? Identify self, unit, patient, room number. Briefly state the problem, what is it, when it happened or started, and how severe. (B) Background: Pertinent background information related to the situation could include the following: The admitting diagnosis and date of admission List of current medications, allergies, IV fluids, and labs Most recent vital signs Lab results: provide the date and time test was done and results of previous tests for comparison This is Amanda from the 4th floor maternal child unit of MRMC calling in regards to Nora Tatum, room 406. Patient in labor and delivery with complaints of “bad headaches for the last week that have turned into constant and not relieved with tylenol; followed by seeing black spots) mother states that she has not been herself lately. Patient denies cramping, contractions and abdominal pain. Denied vaginal bleeding and leaking fluid. Pt admitted to Labor Delivery with complaints of “bad headaches for the last week that have become constant not relieved with Tylenol” Initial dx was Pregnancy induced hypertension. Patient taking Tylenol for pain relief, allergy to latex. Upon assessment of her, we learned that she has 2+ pitting edema in distal upper extremities, 3-4+ Pitting pedal edema and 2-3+ Pretibial edema in Lower Extremities bilaterally. Breath sounds are clear. BP upon arrival was 172/99, U/A was 3+ for protein, DTRs are brisk at 4+; 1 beat of clonus notated. Other clinical information Code status (A) Assessment: What is the nurse’s assessment of the situation? I believe that pt is presenting with Preeclampsia aeb by high blood pressure, protein present in the urine and (R) Recommendation: What is the nurse’s recommendation or what does he/she want? Examples: Notification that patient has been admitted Patient needs to be seen now Order change I would like to have Patient lye on left side to help lower her blood pressure, draw extensive labs and monitoring babies as well; and give patient betamethasone to help mature babies lungs in case of delivery

Clinical 3 SBAR Worksheet

Related Documents

Description

Related Documents

Free up your schedule!

Take 5 seconds to unlock