Amelia Sung Core Clinical Worksheet.pdf

vSim Clinical Worksheet Page 2 Initials: Age: 36 yrs old M/F: F Code Status: Full Code Diagnosis: Active Labor Length of Stay: Unknown Allergies: HCP: Consults: Dr. Jeff Smith Isolation: None Fall Risk: None Transfer: Postpartum IV Type: Location: Fluid/Rate: Critical Labs:None Other Services: None Consults Needed: Lactation Consultant Why is your patient in the hospital (Answer in your own words and include the History of present Illness): Patient is presenting in active labor at 39 weeks of gestation. Health History/Comorbities (that relate to this hospitalization): Patient’s 2nd baby and has a history of shoulder dystocia with the 1st baby. Shift Goals/ Patient Education Needs: 1. Educate patient on shoulder dystocia 2. Monitor EFM and fetal progression 3. Make sure appropriate staff are on standby and ready if complications arise. 4. Deliver healthy baby Path to Discharge: No complications with the baby, no infections or hemorrhage, successful vaginal birth with little to no complications, mother shows she is able to competently care for a newborn, postpartum education and newborn care given, patient has a reliable support team. Path to Death or Injury: Complications with infection and hemorrhage not being handled properly. Not properly monitored. This study source was downloaded by from CourseH on :47:37 GMT -05:00 This study resource was shared via CourseH