Amelia Sung (Core)

SBAR Worksheet (adapted from vSim) ISBAR Student Notes Introduction  Your name, position (Nursing student), unit you are working on  What is the purpose of this communication? My name is Mon-El Edwards, student nurse from labour and birthing room giving update on Amelia Sung’s Condition Situation  What is happening at the moment?  Patient’s name, age, specific reason for visit/admission  Amelia Sung is a 36-year-old Filipino woman, G2P1 (L1) at 39 weeks of gestation, who was admitted 6 hours ago in active labor. At admission she was 4 cm dilated, 100% effaced, -1 station, and fetus in vertex position. Epidural anesthesia was initiated at 0230 hours. At 0330 hours, her membrane ruptured; fluid was clear; dilation was 6 cm and the fetus was still at -1 station in vertex position.  Two hours ago, she was fully dilated and started pushing. The fetal heart rate has been stable with a baseline of 120/min, moderate fetal heart rate variability, and variable decelerations since she started pushing. She is getting tired from pushing, and the descent of the fetal head has been slow. Background  What are the issues that led up to this situation?  Patient’s primary diagnosis, date of admission, current orders Date of Admission: 07/03/21 Primary diagnosis: Active labour  In the past few contractions, fetus has started to crown. She is given O2 at 10 L/min per non-rebreather mask for decelerations, and an IV with lactated Ringer's is running at 125 mL/hr. Her last delivery ended with shoulder dystocia because the baby was large: first-born male delivered vaginally 3 years and 3 months ago, weight: 3,912 g (8 lb 10 oz), length: 55 cm (22 in). The provider has been called and has arrived, so Amelia may continue This study source was downloaded by from CourseH on :45:19 GMT -05:00 This study resource was shared via CourseH pushing. Current orders:  BP Qhour x2 then Q4h  Temp, HR, RR, Q1h  Temp q2h after rupture of membrane intrapartum or it temp is greater than 38  Head to toe assessment  Vaginal exam  Assess IV  Continuous Pulse Ox  Oxygen 10ml/ min per nonrebreather mask Assessment  What do you believe the problem is?  Current pertinent assessment data using head to toe or focused assessment approach,  Pertinent diagnostics  Vital signs BP-138/80 P-93 T-36.9 R-17 O2SAT-99% ra She is flushed with warm dry skin She is in active labour, baby head is crowning upon vaginal exam Recommendation  What should be done to correct this situation?  Any orders or recommendations you have for this patient Prepare for delivery This study source was downloaded by from CourseH on :45:19 GMT -05:00 This study resource was shared via CourseH Powered by TCPDF ()