April 10, 2019
Sharon Williams
Maternity Case 1: Olivia
Jones Documentation
Assignments
1. Document the data from your focused antepartum assessment
of both Ms. Jones and the fetus.
• Olivia Jones, 23 year old African-American Female G1P0 at
36 weeks gestation, diaganosed with severe preeclampsia.
She is admitted to the labor and delivery unit suriveillance,
due to continued progression of preeclampsia, elevated
blood pressure, weight gain, headache, epigastric and
proteinuria
2. Write the situation-background-assessment-recommendation
(SBAR) communications you would use to update the provider
on Ms. Jones’s status at the time of her admission.
S - A woman, Olivia Jones, 36 weeks gestation, diagnosed with
severe preeclampsia. She is complaining of a headache that is not
resolved with acetaminophen and epigastric pain. She is nausea
and fatigue and she states of visual changes, tightness in the
chest. She also states, that she is quieter than normal.