University:
West Coast University
Course:
NURS 662 | Primary Care Pediatric Patient: Theory, Pharmacology and Practice
Academic year:

2021
Views:

5

Pages:

2
Author:

5prinzg1s

Maternity Case 2: Olivia Jones (Complex) Documentation Assignments 1. Document the data from your focused antepartum assessment of both Ms. Jones and the fetus. I initially put up seizure pads and minimized outside stimuli. I then assessed the patient's vital signs and applied oxygen. I attached the fetal heart rate monitor and performed an assessment from head to toe. The fetus was in longitudinal lie, in vertex presentation, and the fetal heart rate was WNL. 2. Write the situation-background-assessment-recommendation (SBAR) communications you would use to update the provider on Ms. Jones’s status at the time of her admission. Olivia Jones is an African American female who is 23 years old. She is G1PO at 36 weeks of gestation, admitted to labor and delivery for assessment and surveillance. At 30 weeks she had an elevated BP of 146/92, proteinuria, and was developing mild preeclampsia. When admitted, she was increasing the following symptoms: negative ketones and glucose, +2 dependent edema, +4 protein dipstick, and facial edema. She is experiencing fatigue, nausea, and headaches not relieved by acetaminophen. Seizure pads were placed, outside stimuli was minimized, and vital signs were assessed. She had increased BP: 170/104 and oxygen was applied as per doctor orders. Fetal heart rate was WNL, a urinary catheter was placed, and magnesium sulphate in sterile water was administered as ordered. 3. Document the teaching you would provide to the patient and her support person prior to administering magnesium sulfate. I would inform the patient and her support person that magnesium sulfate is used to prevent seizures. I would also inform them of the signs and symptoms of toxicity and to report any adverse reactions immediately. 4. Document the administration of the magnesium sulfate bolus and the initiation of the magnesium sulfate infusion. The doctor ordered magnesium sulfate 6g in 100 mL in sterile water at 200 mL/hr, and a second nurse must witness administration. Magnesium sulfate 20 mg in 500 mL in sterile water at 50 mL/hr should not have begun because the first dose is still infusing. 5. Document your reassessment of the patient’s status after administering magnesium sulfate. After administering magnesium sulfate, the doctor ordered for the patient’s pulse and BP, and RR to be monitored every 15 minutes and every hour after infusion. After administration, there was no changes in the patient’s status. The current vitals are HR 102, BP 165/100 mmHg, RR 22, spo2 98%, temp 99 F. The FHR was a baseline of 150.