Docsity
Docsity

Prepare for your exams
Prepare for your exams

Study with the several resources on Docsity


Earn points to download
Earn points to download

Earn points by helping other students or get them with a premium plan


Guidelines and tips
Guidelines and tips

VSIM Carla Hernandez Documentation, Exams of Nursing

VSIM Carla Hernandez Documentation

Typology: Exams

2021/2022

Available from 06/19/2022

Docmerit
Docmerit 🇺🇸

4.2

(16)

621 documents

1 / 6

Toggle sidebar

This page cannot be seen from the preview

Don't miss anything!

bg1
Maternity Case 4: Carla Hernandez
Documentation Assignments
1.
Document your initial assessment data for Carla Hernandez,
including fetal heart rate activity (baseline fetal heart rate,
long-term variability, accelerations, and
decelerations) and
maternal vital signs.
Initial Assessment Data:
Patient: Carla Hernandez
Height: 81 kg
Weight:165 cm
DOB:10/01/1987
Allergies: No known drug allergies
Age:32
G2P1(L1)
Maternal Vital Signs
HR: 89 bpm
Pulse: Present
Blood Pressure: 139/83mmhg
Respiration: 16bpm
SpO2: 97%
Temp: 37C (Oral)
Fetal Heart Rate Activity
EFM: Late Decelerations
FHR: 71bpm
Acceleration: Absent
pf3
pf4
pf5

Partial preview of the text

Download VSIM Carla Hernandez Documentation and more Exams Nursing in PDF only on Docsity!

Maternity Case 4: Carla Hernandez

Documentation Assignments

  1. Document your initial assessment data for Carla Hernandez, including fetal heart rate activity (baseline fetal heart rate, long-term variability, accelerations, and decelerations) and maternal vital signs. Initial Assessment Data:
  • Patient: Carla Hernandez
  • Height: 81 kg
  • Weight:165 cm
  • DOB:10/01/
  • Allergies: No known drug allergies
  • Age:
  • G2P1(L1)
  • Maternal Vital Signs
  • HR: 89 bpm
  • Pulse: Present
  • Blood Pressure: 139/83mmhg
  • Respiration: 16bpm
  • SpO2: 97%
  • Temp: 37C (Oral) Fetal Heart Rate Activity
  • EFM: Late Decelerations
  • FHR: 71bpm
  • Acceleration: Absent
  1. Document the medication(s) that you administered.
  • Terbutaline,0.25 mg, subcutaneously
  • Lactated Ringer's solution IV ,Bolus of 500 mL of, given over 30 minutes
  1. Document your situation-background-assessment- recommendation (SBAR) com- munication to Carla Hernandez’s provider and note any provider orders that were obtained during this simulation activity. Introduction: This is Student Nurse Iyanu Sijuade. I am calling from L&D unit. Situation: I have a Ms. Carla Hernandez here. She’s 32 years old and she was admitted to la- bor and delivery because she was in active labor. She’s 39 5/7 weeks gestation. Her membrane was artificial ruptured to progress the labor. Background She was admitted today and She has a prolapsed cord. The current orders are Lac- tated Ringers 1000mL IV 125 mL/hr continuous infusion, Lactated Ringers 500ml IV bolus (For non-reassuring FHR), Oxygen 10 L/min per non rebreather mask for non reassuring FHR, and Nalbuphine 10 mg IVPB Q 1-2 hrs for pain. Assessment Current vitals are BP: 138/82 mmHg, HR:91 , Temp: 99 f Baby’s Vitals: FHR 71, late deceleration Recommendation I recommend that the provider comes immediately so the patient can be prep for a c- section delivery because of the risk associated with cord prolapse. I recommend the provider to provide additional patient education. Continuous
  1. Document the time that the umbilical cord prolapsed during this simulation and the nursing interventions that were taken, including the timing. Note an evalua- tion of the effectiveness of these measures in resolving the problem identified, and the times that the provider was notified. @0723 : Fetal monitor showed nonreassuring drop in fetal heart rate @0725: Gave oxygen through non rebreather mask @0730: Patient status HR: 89, pulse: present, BP: 138/83, RR:17, SpO2: 98%, EFM: Late decelerations, FHR: 71. @0734: Performed a vaginal exam @0736: Noticed the umbilical cord is prolapsed @0738: Used a sterile gloved hand and pushed the baby’s head upward to relieve pressure on umbilical cord @0740:. Assisted the patient into Trendelenburg position, @0743: Notified the HCP @0746: Administered 0.25 mg of terbutaline and 500 mL over 30 mins of Lactated Ringers @0750: Notified NICU, Anesthesia, and surgery of the situation and to prepare for emergency C section.
  2. Document the fetal heart rate monitoring and any abnormalities. External fetal monitor shows late decelerations with fetal heart rate of 71 beats per minute. The fetal heart rate is not reassuring
  3. Record the communication that was expressed to Carla Hernandez’s husband, Earl. I would have educated the husband and inform him about what is happening to his wife. I would have also explained what cord prolapse is and that we’re doing our best to take care of his wife. I would also inform him about the procedure that Carla would be undergoing by letting him know that she is heading to the surgery unit for a c-section to deliver their baby.
  1. Document how the health care team worked together during this simulation and state your recommendations for improvement.