Question

Maternity Case 1: Olivia Jones

Documentation Assignments

1. Document the data from your focused antepartum assessment of both Ms. Jones and the fetus.

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.

3. Document the teaching you would provide to the patient and her support person prior to administering magnesium sulfate.

4. Document the administration of the magnesium sulfate bolus and the initiation of the magnesium sulfate infusion.

5. Document your reassessment of the patient’s status after administering magnesium sulfate.

Answer 1

ANTE-PARTUM ASSESSMENT OF BOTH Mrs JONES AND THE FETUS.

Vital Statistics

Name- Mrs Olivia Jones

Age

Ward/unit

Inpatient no:

Address

Occupation

Education

Last mentrual period

Expected date of delivery

Gestational age

Obstetric score

Blood group

Gravida- nulligravida / primigravida/ multigravida

Parity - nullipara/ primipara/ multipara/ grandmultipara

Maternal history

Present obsteric history

Planned/unplanned

Minor disorders

Immunization

Exposure to drug/radiation

Abortion history

Smoking /alcohol history

SITUATION BACKGROUND ASSESSMENT RECOMMENDATION

SITUATION

Woman name- Mrs Olivia Jones

Ward-

Hospital no-

Vital signs: pulse, respiration, bloodpressure, temparature

Maternal serum lactate-

Urine output-

Hemorrhage-

Fetal well-being ( pathological CTG)

FBS result-

Obsteric early warning score-

BACKGROUND

Parity-

Gestation age-

Fundal height-

Presentation-

FH rate-

CTG: Normal, Suspicious, Pathological

Antenatal problem-

Treatment given-

ASSESSMENT

I think the problem is................

I am not sure what the problem is but the woman is deteriorating and we need to do something

RECOMMENDATION

Reported to.........

Response...........

MAGNESIUM SULPHATE IN PREGNANCY

It is used to prevent seizures in wowen with preeclampsia, eclampsia and toxicity in pregnancy. It can also help prolong pregnancy for upto two days. This allows drug that speed up your baby's lung development to be administered.

PATIENT EDUCATION REGARDING MAGNESIUM SULPHATE ADMINISTRATION

A) It may cause nausea , vomting and diarrhea.

B) If you have pre-elampsia doctor continue to give Magnesium sulphate through the delivery. Your blood pressure back to normal within 2days after the delivery. Because the condition resolve immediately , close follow -up after delivery is needed.

C) Be aware about Blood pressure fall.

D) magnesium sulphate safe while breastfeeding.

E) Teach adverse effect such as Flushing, palpitation, tremors, headache, blurred vision, oliguria and arrthmia.

MAGNESIUM SULPHATE BOLUS AND INITIATION OD MAGNESIUM SULPHATE INFUSION

Magnesium sulphate 4gm to 6gm loading dose diluted in 100ml fluid administered intravenously over 15minutes, followed by continuous intravenous infusion at 1 to 2gm per hour. Discontinue 24 hours after delivery or last seizure.

REASSESSMENT OF PATIENT AFTER ADMINISTERING MAGNESIUM SULPHATE

Monitor vital signs,

Monitor level of consciousness.

Maintain intake- output chat.

Monitor fetal heart rate if administered during antenal period.

Monitor side effects such nausea, vomiting and irregular pulse rate.

Take ECG to check for any variation.