Amelia Sung Core Clinical

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 vSim Clinical Worksheet Page 2 Alerts: What are you on alert for with this patient? (Signs & Symptoms) 1. Baby getting stuck in the birth canal 2. Fetal decelerations 3. Hemorrhage Management of Care: What needs to be done for this Patient Today? 1. Deliver healthy baby 2. Educate mother about shoulder dystocia 3. Educate mother about possible c-section if baby gets stuck 4. Prepare the NICU for possible complications 5. Administer epidural/pain meds 6. Deliver placenta What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?) 1. Monitor baby with EFM 2. Watch for any abnormal bleeding after labor 3. Monitor the EFM sheets Priorities for Managing the Patient’s Care Today 1. Healthy baby 2. Healthy mother 3. Patient pain is managed 4. Baby does not get stuck or have complications with shoulder dystocia List Complications may occur related to dx, procedure, comorbidities: 1. Cord compression during birth if baby gets stuck 2. Shoulder dystocia, baby can’t come out 3. Patient can hemorrhage after labor or have placenta left over What aspects of the patient care can be Delegated and who can do it? What nursing or medical interventions may prevent the above Alert or complications? 1. Fetal decelerations and V-shaped decelerations This study source was downloaded by from CourseH on :47:37 GMT -05:00 This study resource was shared via CourseH vSim Clinical Worksheet Page 2 2. Baby will be stuck, and mom needs a c-section 3. Mom will have lower B/P and be bleeding. This study source was downloaded by from CourseH on :47:37 GMT -05:00 This study resource was shared via CourseH Powered by TCPDF ()