<여성건강간호학실습 VSIM> Maternity Case 10. Fatime Sanogo (Complex) Documentation Assignments

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<여성건강간호학실습 VSIM> Maternity Case 10. Fatime Sanogo (Complex) Documentation Assignments 입니다.

목차

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).
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.
3. Document the medication(s) you administered to Ms. Sanogo and evaluate each drug’s effectiveness.
4. Document the sequence of events during the simulation (i.e., vital signs, assessment findings, blood loss, nursing interventions, and patient response).
5. Ms. Sanogo is going to be taken back to labor and delivery for a manual examination. Write the transfer note.

본문내용

I'm OOO nurse on ward OO. I'm calling about patient Fatime Sanogo.
I'm calling because I'm concerned that there is a large amount of blood and lochia on the bed. The increase in weigh of the bed pads suggests that approximately 1360mL of lochia was on the pads. The time since the last change of the peds suggests a bleeding rate of approximately 1920ml/hr. The uterus feels soft and boggy. And her heart rate is 118. I have given a 800mg dose of Ibuprofen, a 2mg dose of butorphanol, and perform Fundal Massage. And I assisted the patient into Trendelenburg position. Postpartum hemorrhage continues and she still has pain about 5degrees.
Fatime Sanogo is a 23-year-old primiparous female from Mali in her first hour after vaginal delivery. The patient was admitted yesterday at 0600 hours for oxytocin induction of labor secondary to postdates (41 4/7 weeks). Her stage of expulsion time was over three hours.

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