Amelia Sung Core Clinica

vSim Clinical Worksheet VSIM CLINICAL WORKSHEET vSim Clinical Worksheet Page 2 This study source was downloaded by from CourseH on :47:37 GMT -05:00 Initials: Age: 36 yrs old Diagnosis: Active Labor HCP: Consults: Dr. Jeff Smith Isolation: None IV Type: Critical Labs:None Other Services: None Fall Risk: None Location: M/F: F Code Status: Full Code Length of Stay: Unknown Allergies: Transfer: Postpartum Fluid/Rate: 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 2 nd baby and has a history ofshoulder dystocia with the 1 st 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. vSim Clinical Worksheet Page 2 This study source was downloaded by from CourseH on :47:37 GMT -05:00 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 needsto 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 Prioritiesfor 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 vSim Clinical Worksheet Page 2 This study source was downloaded by from CourseH on :47:37 GMT -05:00 2. Baby will be stuck, and mom needs a c-section 3. Mom will have lower B/P and be bleeding.