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Maternity Case 5: Fatime SanogoDocumentation 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.
m
er as
-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
co
eH w
caseosa, and small clots.
o.
-Pain: Abdomen, severe, sharp, sudden pain, 5 on a scale of 0-10.
rs e
ou urc
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.
o
Hello, this is Jessica from postpartum, I am the nurse for your patient Fatime Sanogo. She is a 23
aC s
year old Hispanic female. She is experiencing a postpartum hemorrhage. The vital signs are,
vi y re
heart rate 123/bpm, pulse is tachycardia and weak, blood pressure is 93/50 mmHg, respirations
are 21, SpO2: 94%, temperature is 37 C. She is conscious. She has experienced blood loss of 800
mL in 25 mins.. Pain scale is 5 out of 10. She needs interventions to stop the bleeding.
ed d
3. Document the medication(s) you administered to Ms. Sanogo and evaluate each drug’s
ar stu
effectiveness.
2 mg butorphanol tartrate IV
is
500 mL lactated Ringer’s solution IV 5 minutes
Oxytoxcin postpartum 500 mL/hr
Th
800 mcg dose misoprostol
5 mg morphine IV
sh
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.
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
This study source was downloaded by 100000796901680 from CourseHero.com on 04-01-2021 17:04:20 GMT -05:00
https://www.coursehero.com/file/50561750/Fatime-Sanogo-Documentation-docx/
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