Maternity Case 3: Olivia Jones
Documentation Assignments
1. Document the data from your focused antepartum assessment of both Ms. Jones and the fetus.
Vital Signs: blood pressure = 174/104; respirations = 22; temperature = 99; pulse = 115; admitting SaO2 = 90% on room air
• headache of 5/10
• RUQ of 4/10
• patient had cough, shortness of breath, fatigue, nausea
• +4 deep tendon reflex with clonus
• +3 pitting edema
• crackles were heard at the base of both lungs upon auscultation
• FHR is 154 bpm
• fetus is in a longitudinal lie and vertex presentation.
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.
Situation: Good morning, is this Dr. Smith? This is Nurse Hyacinth. I am calling in regards to Ms. Jones in room 432. I am concerned because Ms. Jones complained of a 5/10 headache that is unresolved with acetaminophen. She is also presenting nausea, fatigue, epigastric pain, chest tightness, and visual disturbances.
Background: Ms. Jones is a 23-year-old female G1P0 at 36 weeks of gestation. Ms. Jones was already diagnosed with severe preeclampsia.
Assessment
Her vital signs are blood pressure = 174/104; respirations = 22; temperature = 99; pulse = 115; admitting SaO2 = 90% on room air, but this climbed to 98% on 10L O2 via nonrebreather; FHR = 154 Category I. Her preeclampsia appears to be worsening and may be progressing into HELLP syndrome.
Recommendations: I would like you to come and evaluate the patient immediately. Also, can I get an order for magnesium sulfate and an antihypertensive to help manage her condition until you can come and evaluate her
3. Document the teaching you would provide to the patient and her support person prior to administering magnesium sulfate.
• Inform her that she has preeclampsia, a condition that can be devastating to both maternal and fetal well-being
• Inform her that she will be receiving magnesium sulfate
• Explain how this medication will be administered.
4. Document the administration of the magnesium sulfate bolus and the initiation of the magnesium sulfate infusion.
• bolus of magnesium sulfate 6 g in 100 mL of sterile water given over 30 mins
• infusion of magnesium sulfate 20 g in 500 mL of sterile water given at 50 mL/hr
5. Document your reassessment of the patient’s status after administering magnesium sulfate.
I reassessed VS (pulse, BP, and RR), deep tendon reflexes, breath sounds, FHR, and presence of headache, visual changes, SOB, cough, RUQ pain. I also assessed for signs of magnesium toxicity.