Maternity Case 5: Fatime Sanogo
Documentation Assignments
1. Document your initial assessment data for Ms. Sanogo, including vital signs, fundal
assessment (consistency, position, location), lochia assessment (amount, color, odor,
consistency), and pain (location, quality, severity).
Vital signs: HR 108 fast without murmurs, RR 20 chest is moving equally lung sounds are clear
and equal bilaterally, Pulse strong and present, BP 98/50, Temp 99°F, SPO2 96%.
Fundal Assessment: soft and boggy, 1 fingerbreadth above the umbilicus and deviated to the
right.
Lochia Assessment: heavy, 1220ml of lochia rubra with no odor. Consistency is RBC, WBC, small
clots, shreds of decidua, epithelial cells.
Pain: abdominal area and a rating of 5/10.
2. Write the situation-background-assessment-recommendation (SBAR) communications you
would use to update the provider on Ms. Sanogo’s status after your first encounter with her.
This is Nurse Peterson. I’m calling from the postpartum unit about 23 year ols Fatime Sanogo.
I’m calling in regard to her postpartum hemorrhage. Heart rate: 121, pulse: present, BP 93/50
mm/Hg, respirations: 21, conscious state, Spo2:94% Temp: 99° F. She has approximate blood
loss of 760ml in 25 minutes. Pain 5/10. I have assessed the perineum. The patient was place din
Trendelenburg position and a fundal massage was performed, but the uterus failed to firm up. I
have administered 2mg Butorphanol Tartrate IV. I would like you to please advise me as to what
should be done next.
3. Document the medication(s) you administered to Ms. Sanogo and evaluate each drug’s
effectiveness.
2 mg butorphanol tartrate IV – Mrs. Sanogo still reported her pain to be a 5 out of 10. Mrs. Sanogo’s
vital signs remain the same: Heart rate: 119. Pulse: Present. Blood pressure: 93/49 mmHg.
Respiration: 21. Conscious state: Appropriate. SpO2: 95%. Temp: 99° F.
500 mL lactated Ringer’s solution IV 5 minutes: Heart rate: 123. Pulse: Present. Blood pressure:
93/50 mmHg. Respiration: 21. Conscious state: Appropriate. SpO2: 94%. Temp: 99° F.
800-mcg dose misoprostol PR: Heart rate: 117. Pulse: Present. Blood pressure: 94/50 mmHg.
Respiration: 21. Conscious state: Appropriate. SpO2: 99%. Temp: 99° F.
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
, Oxytoxcin postpartum 500 mL/hr: Heart rate: 123. Pulse: Present. Blood pressure: 94/50 mmHg.
Respiration: 21. Conscious state: Appropriate. SpO2: 99%. Temp: 99° F. Uterus begins to firm up
after fundal massage.
4. Document the sequence of events during the simulation (i.e., vital signs, assessment findings,
blood loss, nursing interventions, and patient response).
You arrived at
the patient.
0:00 You introduced yourself.
Patient status - Heart rate: 105. Pulse: Present. Blood pressure: 99/50 mmHg.
0:10 Respiration: 18. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C. EFM:
--. Fetal heart rate: --.
You washed your hands. To maintain patient safety it is important to wash your
0:17
hands as soon as you enter the room.
You identified the patient. To maintain patient safety it is important that you
0:46
quickly identify the patient.
You provided patient education. This is correct. It is important to provide
patient educate to improve understanding of the patient's medical
0:56
condition and methodes and means to manage her condition. Effective
communication and patient education increases patient motivation to comply.
Patient status - Heart rate: 106. Pulse: Present. Blood pressure: 98/50 mmHg.
1:10 Respiration: 19. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C. EFM:
--. Fetal heart rate: --.
1:16 You calmed and supported the patient and the family. This is reasonable.
You listened to the lungs of the patient. The breath sounds are clear and equal
1:40
bilaterally.
You listened to the heart of the patient. There were regular heart sounds
2:02
without murmurs.
Patient status - Heart rate: 108. Pulse: Present. Blood pressure: 98/50 mmHg.
2:10 Respiration: 20. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C. EFM:
--. Fetal heart rate: --.
You looked for normal breathing. She is breathing at 20 breaths per minute.
2:13
The chest is moving equally.
You measured the <Bloodpressure>blood pressure<> at 96/50
2:40 mmHg. It is appropriate to monitor the patient by measuring the blood
pressure.
Patient status - Heart rate: 109. Pulse: Present. Blood pressure: 96/50 mmHg.
3:10 Respiration: 20. Conscious state: Appropriate. SpO2: 96%. Temp: 37 C. EFM:
--. Fetal heart rate: --.
You attached the <Pulseoximeter>pulse oximeter.<> This was
3:17
indicated by order.
You checked the radial pulse. The pulse is strong, 110 per minute and regular.
3:31
It is correct to assess the patient's vital signs.
You checked the <Temperature>temperature<> at the mouth. The
3:54
temperature was 37 C.
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
Documentation Assignments
1. Document your initial assessment data for Ms. Sanogo, including vital signs, fundal
assessment (consistency, position, location), lochia assessment (amount, color, odor,
consistency), and pain (location, quality, severity).
Vital signs: HR 108 fast without murmurs, RR 20 chest is moving equally lung sounds are clear
and equal bilaterally, Pulse strong and present, BP 98/50, Temp 99°F, SPO2 96%.
Fundal Assessment: soft and boggy, 1 fingerbreadth above the umbilicus and deviated to the
right.
Lochia Assessment: heavy, 1220ml of lochia rubra with no odor. Consistency is RBC, WBC, small
clots, shreds of decidua, epithelial cells.
Pain: abdominal area and a rating of 5/10.
2. Write the situation-background-assessment-recommendation (SBAR) communications you
would use to update the provider on Ms. Sanogo’s status after your first encounter with her.
This is Nurse Peterson. I’m calling from the postpartum unit about 23 year ols Fatime Sanogo.
I’m calling in regard to her postpartum hemorrhage. Heart rate: 121, pulse: present, BP 93/50
mm/Hg, respirations: 21, conscious state, Spo2:94% Temp: 99° F. She has approximate blood
loss of 760ml in 25 minutes. Pain 5/10. I have assessed the perineum. The patient was place din
Trendelenburg position and a fundal massage was performed, but the uterus failed to firm up. I
have administered 2mg Butorphanol Tartrate IV. I would like you to please advise me as to what
should be done next.
3. Document the medication(s) you administered to Ms. Sanogo and evaluate each drug’s
effectiveness.
2 mg butorphanol tartrate IV – Mrs. Sanogo still reported her pain to be a 5 out of 10. Mrs. Sanogo’s
vital signs remain the same: Heart rate: 119. Pulse: Present. Blood pressure: 93/49 mmHg.
Respiration: 21. Conscious state: Appropriate. SpO2: 95%. Temp: 99° F.
500 mL lactated Ringer’s solution IV 5 minutes: Heart rate: 123. Pulse: Present. Blood pressure:
93/50 mmHg. Respiration: 21. Conscious state: Appropriate. SpO2: 94%. Temp: 99° F.
800-mcg dose misoprostol PR: Heart rate: 117. Pulse: Present. Blood pressure: 94/50 mmHg.
Respiration: 21. Conscious state: Appropriate. SpO2: 99%. Temp: 99° F.
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
, Oxytoxcin postpartum 500 mL/hr: Heart rate: 123. Pulse: Present. Blood pressure: 94/50 mmHg.
Respiration: 21. Conscious state: Appropriate. SpO2: 99%. Temp: 99° F. Uterus begins to firm up
after fundal massage.
4. Document the sequence of events during the simulation (i.e., vital signs, assessment findings,
blood loss, nursing interventions, and patient response).
You arrived at
the patient.
0:00 You introduced yourself.
Patient status - Heart rate: 105. Pulse: Present. Blood pressure: 99/50 mmHg.
0:10 Respiration: 18. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C. EFM:
--. Fetal heart rate: --.
You washed your hands. To maintain patient safety it is important to wash your
0:17
hands as soon as you enter the room.
You identified the patient. To maintain patient safety it is important that you
0:46
quickly identify the patient.
You provided patient education. This is correct. It is important to provide
patient educate to improve understanding of the patient's medical
0:56
condition and methodes and means to manage her condition. Effective
communication and patient education increases patient motivation to comply.
Patient status - Heart rate: 106. Pulse: Present. Blood pressure: 98/50 mmHg.
1:10 Respiration: 19. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C. EFM:
--. Fetal heart rate: --.
1:16 You calmed and supported the patient and the family. This is reasonable.
You listened to the lungs of the patient. The breath sounds are clear and equal
1:40
bilaterally.
You listened to the heart of the patient. There were regular heart sounds
2:02
without murmurs.
Patient status - Heart rate: 108. Pulse: Present. Blood pressure: 98/50 mmHg.
2:10 Respiration: 20. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C. EFM:
--. Fetal heart rate: --.
You looked for normal breathing. She is breathing at 20 breaths per minute.
2:13
The chest is moving equally.
You measured the <Bloodpressure>blood pressure<> at 96/50
2:40 mmHg. It is appropriate to monitor the patient by measuring the blood
pressure.
Patient status - Heart rate: 109. Pulse: Present. Blood pressure: 96/50 mmHg.
3:10 Respiration: 20. Conscious state: Appropriate. SpO2: 96%. Temp: 37 C. EFM:
--. Fetal heart rate: --.
You attached the <Pulseoximeter>pulse oximeter.<> This was
3:17
indicated by order.
You checked the radial pulse. The pulse is strong, 110 per minute and regular.
3:31
It is correct to assess the patient's vital signs.
You checked the <Temperature>temperature<> at the mouth. The
3:54
temperature was 37 C.
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
