VSIM Clinical Worksheet

Name: Date: November 2, 2022 Initials: FS Age: 23 y.o. M/F: F Code Status: Full Diagnosis: Induction of Labor secondary to postdates Length of stay: 1 day Allergies: No Known HCP: Dr. Schmoe Consults: Lactation Services Isolation: None Fall Risk: HIGH Transfer: Labor and Delivery IV Type: Oxytocin Induction (mU/min) 20 mU/min 500 ml NS IV Location: Mother and Baby Unit Fluid/Rate: Oxytocin Induction (mU/min) 20 mU/min 500 ml NS IV Critical labs: HCT 43 RBC 5 Why is your patient in the hospital: (answer in your own words and include the history of present illness)? The patient is a G1T0P1A0L1 at 41 4/7 weeks gestation who delivered a female 4082g (9 lbs.) neonate with 9 and 9 Apgar score. She had a second-degree perineal laceration during delivery but has been repaired. The placenta was delivered manually and followed with bleeding. It was controlled with a fundal massage and an infusion of oxytocin. She is diagnosed with induction secondary to postdates. She can’t void and has a boggy uterus. Health History/Comorbidities: (that relate to this hospitalization) The patient had prolonged second stage labor, second-degree perineal laceration, and placenta was manually removed. Shift Goals/Patient Education Needs: 1. First goal: The client will have adequate tissue perfusion. 2. Second goal: The client will have a decrease/control in bleeding. 3. Third goal: The client will have a patent airway, adequate oxygenation through continuous pulse oximetry and administer oxygen therapy her HCP order. 4. Fourth goal: The patient will have a stable vital sign within client’s normal parameters.