Olivia Jones - Documentation

Documentation Assignments 1. Document the data from your focused antepartum assessment of both Ms. Jones and the fetus. Ms. Olivia Jones is a 23 year old African American female, G1P0 at 36 weeks gestation. She gained three pounds since prenatal visit 1 week ago. Portein dipstick is +4, negative ketones, negative glucose, +2 dependent edema, and acial puffiness. She c/o headache that is not rsolved with acetaminophen. She prsents with N/V and chest tightness. The fetus is active, however, patient states that it is a bit quieter than normal. There is a possibility of premature rupture of membranes. An IV with LR is running at 125mL/hr. She has been diagnosed with severe preeclampsia. Her vitals were HR 116, Pulse present, B/P 171/102, RR 22, Conscious state is appropriate, SpO2 89%, Temp 98.6F. Bilateral base crackles, chest moving equally. Regular heart sounds without murmurs. Moderate to severe pitting edema graded +3. She reports pain uppercenter of stomach and under right breast. She reports headache across forehead 5/10. Skin is cool and very sweaty. Bladder contained 82mL of urine. FHR 151 bpm. Fetus is in longitudinal lie, in vertex presentation. 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. Situation: This is nurse Sandra calling from L&D regarding your patient Ms. Olivia and I am concerned about her blood pressure.