Maternity Case 5: Fatime Sanogo Documentation Assignments, Answered by expert tutors, latest spring 2021/2022.

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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).  Vital signs: Heart rate: 111. Pulse: Present and strong. Blood pressure: 98/50 mmHg. Respiration: 20. Conscious state: Appropriate. SpO2: 96%. Temp: 37  Fundal assessment: Soft and boggy, above the umbilicus, and deviated to the right  Lochia Assessment: Moderate - 1240 mL, lochia rubra, stale and musty odor, and consistency is epitheal cells, RBC, WBC, bacteria, shreds of decidua, fetal meconium, lanugo (baby hair), vernix caseosa, and small clots.  Pain: Adominal area, severe, sharp, and sudden pain, and 5 on a scale of 0-10. 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.  This is Mary Bui. I’m calling from postpartum. I am calling about 23 year old Hispanic female named Fatime Sanogo. The problem I am calling about is postpartum hemorrhage. Heart rate: 123. Pulse: Pulse tachycardia and weak. Blood pressure: 93/50 mmHg. Respiration: 21. Conscious state: Appropriate. SpO2: 94%. Temp: 37 C. She had blood loss of 800 mL in 25 mins.. Pain scale is 5 out of 10. I would like advice please on what to do next. 3. Document the medication(s) you administered to Ms. Sanogo and evaluate each drug’s effectiveness.  2 mg butorphanol tartrate IV – Mrs. Sanogo still reported her pain to be a 5 out of 10. Mrs. Sanogo’s vital signs remain the same: Heart rate: 119. Pulse: Present. Blood pressure: 93/49 mmHg. Respiration: 21. Conscious state: Appropriate. SpO2: 95%. Temp: 37 C.  500 mL lactated Ringer’s solution IV 5 minutes: Heart rate: 123. Pulse: Present. Blood pressure: 93/50 mmHg. Respiration: 21. Conscious state: Appropriate. SpO2: 94%. Temp: 37 C.  Oxytoxcin postpartum 500 mL/hr: Heart rate: 123. Pulse: Present. Blood pressure: 94/50 mmHg. Respiration: 21. Conscious state: Appropriate. SpO2: 94%. Temp: 37 C  800-mcg dose misoprostol PR: Uterine tone: uterine atony and vital signs: Heart rate: 117. Pulse: Present. Blood pressure: 94/50 mmHg. Respiration: 21. Conscious state: Appropriate. SpO2: 99%. Temp: 37 C. From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health. This study source was downloaded by 100000831988016 from CourseHero.com on 04-05-2022 14:04:59 GMT -05:00 https://www.coursehero.com/file/48728781/MaternityCase5-DA-1docx/  5 mg morphine IV: Mrs. Sanogo stated that she felt better and vital signs changed: Heart rate: 117. Pulse: Present. Blood pressure: 91/49 mmHg. Respiration: 21. Conscious state: Appropriate. SpO2: 99%. Temp: 37 C 4. Document the sequence of events during the simulation (i.e., vital signs, assessment findings, blood loss, nursing interventions, and patient response).  Heart rate: 111. Pulse: Present. Blood pressure: 98/50 mmHg. Respiration: 20. Conscious state: Appropriate. SpO2: 96%. Temp: 37 C.  Heart rate: 123. Pulse: Present. Blood pressure: 93/50 mmHg. Respiration: 21. Conscious state: Appropriate. SpO2: 94%. Temp: 37 C.  Heart rate: 113. Pulse: Present. Blood pressure: 93/55 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 99%. Temp: 37  The uterus did not firm up properly.  The uterus was soft and boggy.  Pernium: There was 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 vaginal. She was bleeding at a moderate rate.  The increase in weight of the bed pads suggests that approximately 1240 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.  Pain score of 5 out of 10.  The bladder contained 300 mL of urine.  Assisted the patient into lying position.  You performed fundal massage.  Assesed the patient’s perinium.  Checked for blood, lochia, and fluid on the bed.  Administered 2 mg of butorphanol tartrate IV.  Phoned the provider in order to discuss the patient.  Started a bolus of 500 mL of lactated Ringer solution IV, given over 5 minutes.  Started infusing oxytocin postpartum (mL/hr) at 500 mL/hr. This was indicated by order.  Gave the patient 100% oxygen from a nonrebreathing mask.  Performed a straight catheterization.  Adminstered 800-mcg dose of misoprostol rectally.  Administered 5 mg of morphine IV. 5. Ms. Sanogo is going to be taken back to labor and delivery for a manual examination. Write the transfer note. From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health. This study source was downloaded by 100000831988016 from CourseHero.com on 04-05-2022 14:04:59 GMT -05:00 https://www.coursehero.com/file/48728781/MaternityCase5-DA-1docx/  Fatime Sanogo is being transferred from postpartum to labor and delivery. She has retained placental fragments and experiencing postpartum hemorrhaging. Placental fragments needs to be taken out and she can return back to postpartum after hemorrhaging has stopped. [Show More]

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