Maternity Case 5 Fatime Sanogo

Maternity Case 5: Fatime Sanogo Documentation Assignments 1. Document your initial assessment data for Ms. Sanogo, including vital signs, fundal assessment (consistency, position, location), lochia assessment (amount, color, odor, consistency), and pain (location, quality, severity). a. Pulse: Present, Blood pressure: 101/51 mmHg, Respiration: 18. Conscious state: Appropriate, SpO2: 97%, Temp: 37 C; 20 breaths per minute – chest moving equally; PERRLA and pupils 7mm; heavy red present lochia on pads/bed suggesting 1190 mL of lochia was on the pads; uterus was soft and boggy; pain of 5 out of 10 on 1 to 10 scale located in the abdomen 2. Write the situation-background-assessment-recommendation (SBAR) communications you would use to update the provider on Ms. Sanogo’s status after your first encounter with her. a. S: Ms Sanogo, heavy blood and lochia present suggesting postpartum hemmorage b. B: 14 hours postpartum - delivered 9 lb baby at 0605; had a 2nd degree perineal laceration repair after prolonged labor c. A: Patient status/VS: Heart rate: 112. Pulse: Present. Blood pressure: 94/49 mmHg. Respiration: 21, chest moves equally; Conscious state: Appropriate. SpO2: 95%. Temp: 37 C; heavy bloody lochia present on pads and bed; performed fundal massage; uterus did not firm up properly; is soft and boggy. After changing/weighing the bed pads; increase in weight of the bed pads suggests that approximately 1190 mL of lochia was on the pads- suggests a bleeding rate of approximately 1980 mL/hr; assisted the patient into Trendelenburg position; bladder scan showed 300 mL of urine d. R: Pt cannot relief bladder I would like to sugges a stratight cath. Also, provide additional fluids and Oxytocin or similar medicaiotn to promote utertiner contraction and stop the hemmoraging; also pain medication for the patients pain; also suggest O2 administration 3. Document the medication(s) you administered to Ms. Sanogo and evaluate each drug’s effectiveness. a. oxytocin postpartum (mL/hr) at 500 mL/hr b. 800mcg misoprostol given rectally c. morphine 5 mg IV d. butorphanol 2mg IV 4. Document the sequence of events during the simulation (i.e., vital signs, assessment findings, blood loss, nursing interventions, and patient response).  Introduced self and ID’d the PT  asked the patient if she had any pain. (In pain) She replied: 'Yes! Ahh...'  Patient status - Heart rate: 105. Pulse: Present. Blood pressure: 98/49 mmHg. Respiration: 20. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C  Asked about pain on 1 to 10 scale; stated 5. Located in Belly; I asked if she wanted something for pain and she replied yes  Checked pt pupils and they were 7 mm and reactive  Patient status - Heart rate: 106. Pulse: Present. Blood pressure: 97/50 mmHg. Respiration: 20. Conscious state: Appropriate. SpO2: 96%. Temp: 37 From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health. Assessed the Pt’s IV site: no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact.  Patient vitals = Heart rate: 108. Pulse: Present. Blood pressure: 97/50 mmHg. Respiration: 20. Conscious state: Appropriate. SpO2: 96%. Temp: 37 C  administered 2 mg of butorphanol tartrate IV  changed and weighed the bed pads. The increase in weight of the bed pads suggests that approximately 1190 mL of lochia was on the pads. The time since the last change of the pads suggests a bleeding rate of approximately 1980 mL/hr  patient into Trendelenburg position  Scanned the bladder: bladder contained 300 mL of urine.  Assessed Pt perineum: showerd minimal redness, minimal edema, no echimosis, and no discharge from the repair, and it is well approximated. A lot of blood and lochia was seen in the vagina. She was bleeding at a moderate rate  Palpated the fundus of uterus - The uterus was soft and boggy.  Performed a fundal massage: the uterus did not contract properly  phoned the provider in order to discuss the patient  Verified oxytocin dosage with another nursestarted infusing oxytocin postpartum (mL/hr) at 500 mL/hr. This was indicated by the phone order by the provider  Then gave bolus of 500 mL of lactated Ringer's solution IV, given over 30 minutes  Assessed IV site: site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact. Assessed vitals: Heart rate: 119. Pulse: Present. Blood pressure: 93/49 mmHg. Respiration: 21. Conscious state: Appropriate. SpO2: 94%. Temp: 37 C  Administered 100% oxygen 10L/hour via nonrebreathing mask  Performed a straight catheterization. This was indicated by order. The bladder was emptied. There was about 300 ml of urine in the bladder.  Assessed Pain and phoned provider additionally  800-mcg dose of misoprostol was given rectally. This was indicated by the phone order  Also administered 5 mg of morphine IV and performed assessment: Heart rate: 115. Pulse: Present. Blood pressure: 90/51 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 99%. Temp: 37 C. IV site assessed, CD&I  Calmed and supported the patient and the family.  Assessed Pt pain on 1-10 scale; replied yes, some pain 5. Ms. Sanogo is going to be taken back to labor and delivery for a manual examination. Write the transfer note. a. Ms. Sanugo is being transferred back to labor and delievery unit. Vital signs are within normal range but shes experiences signs and symptoms of post partum hemorrhage and pain of 5 on 0-10 scale. Keep close monitor possible patient hemmorage 