NUR 4150 Mother Baby Simulation PRE SIM

NUR 4150 Mother Baby Simulation PRE SIM

Thank you for reading this post, don't forget to subscribe!

 

**Monday simulation must be submitted by Friday at 2359, Wednesday simulation must be submitted by Sunday at 2359**

 

Review client’s medical record (Susan Wilson) 

  • Provider Charts:
    • Provider Orders-Need to review and be aware of orders prior to SIM
    • H & P-Need to review and be aware of client history
    • Progress Notes-Need to review notes
    • Vital Signs-Review
    • Client Charting– Review
  • Provider Prescriptions (orders)
  • Labs: Review and understand abnormal and blood typing

 

NUR 4150 Mother Baby Simulation PRE SIM: Pathophysiology (7 points total)

 

  1. Compare estimated blood loss (EBL) to quantified blood loss (QBL) as utilized in the obstetrical setting. Explain “how” loss is calculated. Which part of the nursing process does this satisfy? (Cite your sources; 2 points)

 

  1. Complete the following postpartum hemorrhage care management (Cite your sources; 3 points/1 point each section):
    1. List 3 factors that place Susan at risk for a postpartum hemorrhage:
      1. __________________________________________________
      2. __________________________________________________
  • __________________________________________________
  1. List 3 nursing assessments to manage a postpartum hemorrhage:
    1. __________________________________________________
    2. __________________________________________________
  • __________________________________________________
  1. List 3 nursing interventions to manage a postpartum hemorrhage:
    1. _________________________________________________
    2. _________________________________________________
  • _________________________________________________

 

  1. Complete the following newborn care management (Cite your sources; 2 points/1 point each section):
    1. List 3 nursing assessments for the newborn transition period:
      1. _________________________________________________
      2. _________________________________________________
  • _________________________________________________
  1. List 3 nursing interventions anticipated in the newborn transition period:
    1. _________________________________________________
    2. _________________________________________________
  • _________________________________________________

 

Potential Nursing Diagnoses (1 point/ 0.25 point each)

 

Document two potential nursing diagnoses for Susan based on her pathophysiology and two potential nursing diagnoses for her neonate based on physiology.   As these are potential nursing diagnoses, your diagnoses will be at “Risk For” nursing diagnosis.  Remember to include the nursing diagnosis and the related to factor in your potential nursing diagnoses for your client.  Please come to simulation prepared with appropriate interventions for your client based on your potential nursing diagnoses. 

 

 

Potential Nursing Diagnosis #1-Susan
·          
Potential Nursing Diagnosis #2-Susan
·
Potential Nursing Diagnosis #3-Neonate
·
Potential Nursing Diagnosis #4-Neonate
·          

 

 

 

Communication (2 points / 0.5 point each)

 

You are the primary nurse calling Dr. Loose to communicate the current cervical exam at 0600. Using the space provided, briefly write out the “SBAR” you would use to effectively report your findings.

Situation: (Who are you? Who are you reporting about?)

 

Background: (Pertinent prenatal/medical history)

 

Assessment Findings: (VS, fetal heart tones contraction pattern, etc.)

 

Recommendation/Request: (What do you want? What do you suggest?)

 

Medical Record for Susan Wilson

Client Information:

Name: Susan Wilson

DOB: 4/13/___

Age: 42

Provider:  Kelly Loose MD

Record number: 5600326

Home address: 1112 Main St

City: Grand Rapids

St: MI

Zip code:

49505

Phone: 555-432-9678

Marital status: married:  Jarod Wilson

Education:  College

Occupation: Preschool teacher

 

Father of Baby: Jarod Wilson currently deployed

 

Prenatal Visits

Add prenatal visits

Visit Number 1 2 3 4 5 6 7 8
Date/Weeks Gestation 10 weeks 14 weeks 18 weeks 22 weeks 26 weeks 30 weeks 32 weeks 34
Medications         Rhogam      
Weight 147 150 153 157 162 166 170 174
Blood Pressure 120/68 122/70 118/68 120/70 124/70 116/66 122/70 118/70
Urine Protein Negative Negative Negative Negative Negative Negative Negative Negative
Urine Glucose Negative Negative Negative Negative Negative Negative Negative Negative
Edema None None None None None None None None
Fetal Heart Rate 155 155 150 145 145 140 135 140
Fundal Height Not palpated 14 18 22 26 29 33 34
Fetal Activity NA NA NA Present Present Present Present Present
Presentation NA NA NA NA Cephalic Cephalic Cephalic Cephalic
Preterm Labor Symptoms None None None None None None None None
Next Appointment 4 weeks 4 weeks 4 weeks 4 weeks 4 weeks 2 weeks 2 weeks 2 weeks
Initials KL KL KL KL KL KL KL KL

 

Medical History

 

History of Substance Use

Tobacco

Positive History of Tobacco Use

Yes No

Number of Years Smoking

-SELECT- Less than 1 1 2 3 4 5 6 7 8 9 10 or More

Smoking During this Pregnancy

Yes No

Type of Tobacco Used:

Alcohol

Positive History of Alcohol Use

Yes No

Number of Years of Alcohol Use

-SELECT- Less than 1 1 2 3 4 5 6 7 8 9 10 or More

Alcohol Use During this Pregnancy

Yes No

Drinks per Day (average):

-SELECT- 1 2 3 4 5 or more

Illicit Drug Use (Prescription or Street)

Positive History of Illicit Drug Use

Yes No

Number of Years of Drug Use

-SELECT- Less than 1 1 2 3 4 5 6 7 8 9 10 or More

Drug use During this Pregnancy

Yes No

Drugs Used:

Family History

Pertinent Family History:

Review of Systems (serious illness, injury, chronic diseases)

Pertinent Review of Systems:

Allergies

Allergies:

Immunization Status

Tetanus, Diphtheria, Pertussis (Td/Tdap):

Current Partial Doses Received

Never Received Cannot Remember

Human Papillomavirus (HPV):

Current Partial Doses Received

Never Received Cannot Remember

Varicella:

Current Partial Doses Received

Never Received Cannot Remember

 

 

Zoster:

Current

Never Received Cannot Remember

Measles, Mumps, Rubella (MMR):

Current Partial Doses Received

Never Received Cannot Remember

Influenza:

Current

Never Received Cannot Remember

Pneumococcal:

Current Partial Doses Received

Never Received Cannot Remember

Hepatitis A:

Current Partial Doses Received

Never Received Cannot Remember

Hepatitis B:

Current Partial Doses Received

Never Received Cannot Remember

Meningococcal:

Current

Never Received Cannot Remember

 

 

 

 

Admission History

 

Created By: B Moore, RN  Mon | 23:55

Completed By:  B Moore, RN  Mon | 23:55

Admission Data

Informant/Historian

Information received from: Self

Pregnancy Related: yes

Arrived By: Ambulatory

This Admission: OB triage

 

Health History

Recent Fever Requiring Antibiotics

No recent fever

 

Sexuality/Reproductive

Birth control used: Yes, Prior to this pregnancy.  “Worked fine, not problems really”

Sex of partners: Male

Number of sex partners: 1

Sexually active: Yes

Respiratory Problems:  Asthma, “Has not bothered me for a while. Couple years ago had bad allergies and it bothered me.”

 

 

Previous Pregnancy

How long ago? 15 years 12 years 8 years
Gestational Weeks 39.6 40.1 38.6
Type of Delivery Spontaneous vaginal birth Spontaneous vaginal birth Spontaneous vaginal birth
Duration of Labor “maybe 12 hrs” “about 6 hours” “about 8 hours.”
Complications None None None
Outcome Living male Living male Living male

 

Last Oral Intake

Description of intake:  Ice cream

Time: 20:00

Day: Yesterday evening

 

History of Current Pregnancy

Is fetus active?  Yes “Moves all the time.”

 

Multiple gestation?  No

 

Group B Streptococcus status:  Negative

 

Risk factors identified:  Exercise, seatbelts, Pap smears, mammograms

 

Provider name:  Kelly Loose, MD

 

Received prenatal care?  Yes

 

 

 

 

 

Obstetric History

Living:  3

Abortion: 0

Preterm: 0

Term: 3

Para: 3

Gravida: 4

 

Are you breastfeeding?  Yes “I breast fed my other 3 for 7-9 months.  The beginning was the hardest after the first week went great.”

 

Last menstrual period: 39.5 weeks ago

Confirmed by ultrasound? Yes

Baby’s due: 2 days from now

Are you pregnant? Yes

 

 

 

Planning for Hospital Stay

Newborn Plans

Newborn nutrition:  Breastfeeding

Pediatrician name:  Dr. Brown

 

Plans for Birth

Name(s) of person(s) to be present:   Jarod “my husband was supposed to be here but he is deployed right now.  He can’t leave until tomorrow.”

Education Level:  Graduated from college

How do you prefer instructions? Spoken and written

Do you have a living will?  “Yes the military requires it.”

 

Primary Language:   English

Do you have barriers to learning?  No

Can you write?  Yes

Can you read?  Yes

 

Why were you admitted to the hospital?

“My water broke.”

How long has the problem existed? ”Today about an hour ago.”

 

With whom should we communicate while you are hospitalized?  Self “I guess my parents and Jarod if he calls.”

Will family/others be staying with you during hospitalization?  “I am not sure I still have not been able to reach Jarod.  My parents are with the boys.”

 

Allergy Information

Do you have any known allergies to drugs, food, or environmental items?   Not really some outside stuff”

 

Home Medication Information

Do you take any medications, herbal products, vitamins, or supplements at home?  Yes

 

Information Received From:

Self

 

Prescription Medications

Name Dose/Form Route Frequency Last Dose Indication Entered By Entered Day/Time
Prenatal Vitamins with Minerals and Iron – (StuartNatal, StuartNatal Plus 3, Duet, NataChew, Prenatabs) 1 tab/Tablet Oral Daily Prenatal health B Moore, RN Mon 23:55
Albuterol HFA Inhaler – (Ventolin HFA, Proventil HFA, ProAir HFA) 90 mcg/actuation 2 inhalations/Inhalation Aerosol Inhaled Every 4 Hours PRN

Years ago

Have problems breathing. B Moore, RN Mon 23:55

Drug Screen

 

Street/Recreational/Excessive Prescription Drug Use: “I have never used street/recreational/excessive prescription drugs.” Urine sent for tox screen.

 

 

Smoking Screen

 

Smoker Status:  “I have never used tobacco.” Do you live with a smoker? No

 

 

Alcohol Screen : Do you drink alcohol?  No

 

 

Mobility and Physical Therapy Screen

Does patient have orders for physical therapy? No

 

 

Morse Fall Scale

Total Fall Risk Score

Risk Score:

20

 

Fall Risk Score and Preventative Measures Implemented

Fall Risk Level:

Low Risk

 

Fall Risk Measures:

Implement <b>Low</b>  Risk Fall Prevention Interventions:<br>All admitted patients, orient to surroundings, patient and family education about risk, toileting program, bed in low position, evaluate medication response, personal items in reach, night light as appropriate, nonskid footware, decrease room clutter.

 

Mental Status

 

Oriented to Own Ability=0

 

Gait

 

Normal/Bedrest/Wheelchair=0

 

IV or IV Access

 

Yes=20

 

Ambulatory Aid

 

None/Bedrest/Nurse Assist=0

 

Secondary Diagnosis

 

No=0

 

History of Falling

 

No=0

 

Fall Risk Assessment

Risk Level

 

Low risk

 

Morse Fall Scale

Fall Risk Assessment score:

20

 

Activity/Occupational Therapy Screen

New Occupational Therapy Screen

 

No new occupational therapy problems noted at this time

 

Psychosocial Screen

Cognitive Ability

Memory

Recall 5 object names 3 minutes after mention?  Yes

 

Can recall place of birth? Yes

 

Can recall year Born?  Yes

 

Can recall mother’s maiden name?  Yes

 

Abstract Reasoning (Able to Report Logical Response)

A bird in the hand is worth two in the bush: Yes correctly explained this statement.

 

A rolling stone gathers no moss: Yes

 

Attention Span

Can correctly say the days of the week: Yes

 

Can correctly spell “world” backwards: Yes

 

Judgment

How well is client meeting social and family obligations? Meets

 

What are your plans for the future? Appropriate

 

Comprehension

Can follow simple directions: Yes

 

Can follow complex directions: Yes

 

Aphasia

Can communicate verbally: Yes

 

Appearance

Grooming: Clean, with good grooming

 

 

 

Emotional Status

Body language: Erect posture with good eye contact

 

Over the past 2 weeks, have you felt down, depressed, or hopeless? No

 

Over the past 2 weeks, have you had little interest in doing things? No

 

Orientation

Oriented to time: Yes

 

Oriented to person: Yes

 

Oriented to place: Yes

 

Nutrition Screen

Food Preferences/Diet Considerations

Diet before hospitalization, including snacks: 3 meals per day, usually an evening snack before bed.

 

Total Score

 

0

 

Illness/Injury Nutrition Screen

Fever/infection/sepsis:  0 = No

 

Polytrauma/multiple fracture:  0 = No

 

Tube feeding/total parenteral nutrition (TPN):  0 = No

 

Pressure ulcer/open wounds/draining fistula:  0 = No

 

Head/neck/mouth surgery:  0 = No

 

Cachexia or physical signs of weight loss:  0 = No

 

Total Score  0

 

General Nutrition Screen

Diet information requested by patient:  0 = No

 

Tube feeding/total parenteral nutrition (TPN):  0 = No

 

Pressure ulcer/open wounds/draining fistula:  0 = No

 

Role/Relationship

Social Interactions

 

Describes self as outgoing and friendly

 

Social Resources

 

Will have strong support/help with newborn

 

Feelings of Readiness for Newborn Care

 

Feels ready, eager

 

 

Readiness for Newborn

Supplies and equipment at home:

Car seat

 

Crib

 

Diapers

 

Clothing

 

Hygiene supplies

 

Role Performance

 

Good self-identity and role identity

 

Caregiver Role

 

Primary caregiver in family for 1 or more family members

 

Family Processes

 

Participates as decision-maker in family

 

Marital or Partner Status

 

Married

 

 

Case Management and Social Work Screen

Case Management

Do you currently have a home health nurse visiting you?  No

 

Was client admitted from another hospital or facility?  No

 

Do you currently use oxygen or medical equipment at home?  No

 

Do you anticipate the need for home infusion or enteral needs?  No

 

Have you been hospitalized more than twice in the past 2 months?  No

 

Abuse Screen

Are there physical injuries consistent with the patient’s history?  No

 

Is there any person who threatens you or hurts you?  No

 

Have you been forced into sexual activities against your wishes?  No

 

Case Management

Do you anticipate the need for health services or medical equipment?  No

 

Do you have difficulty obtaining your medications?  No

 

Do you anticipate the need for self-injections at home?  No

 

Abuse Screen

Have you been hit, slapped, kicked or physically hurt by someone in the past year?  No

 

Are you afraid of your partner or someone else?  No

 

Have you been emotionally or physically abused by your partner or someone else?  No

 

Social Work

Is client homeless or unidentified?  No

 

Will you need assistance after discharge?  No

 

Is client a candidate for nursing home care?  No

 

Will you have assistance after discharge?  Yes

 

Culture/Spirituality

Religious Preference

 

Christian, reformed

 

Do you want clergy to visit you while you are in the hospital?  No

 

Are there religious, cultural, or ethnic concerns we should consider while you are in the hospital? No

 

Pressure Sore Risk Assessment: Braden Scale

The Braden Scale for Predicting Pressure Sore Risk

Total Braden Scale score:

21

 

Total Braden Scale Pressure Sore Risk Factor

 

Not at Risk: Score of 19 or higher.

 

 

Braden Scale

Total Braden Scale Pressure Score Risk Factor

Total Braden Scale Score

Not at Risk

 

 

21

 

Friction and Shear

Degree to which skin is at risk for friction or shearing wounds:

NO APPARENT PROBLEM = 3 Moves in bed and chair independently and has sufficient muscle strength to lift up completely during move.Maintains good position in bed or chair.

 

Nutrition

Usual food intake pattern:

ADEQUATE = 3 Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs.

 

Mobility

Ability to change and control body position:

NO LIMITATION = 4 Makes major and frequent changes in position without assistance.

 

Activity

Degree of physical activity:

WALKS OCCASIONALLY = 3 Walks occasionally during day, but for short distances, with or without assistance. Spends majority of each shift in bed or chair.

 

Moisture

Degree to which skin is exposed to moisture:

RARELY MOIST = 4 Skin is usually dry. Linen only requires changing at routine intervals.

 

Sensory Perception

Ability to respond meaningfully to pressure-related discomfort:

NO IMPAIRMENT = 4 Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.

 

Pain Assessment

Intensity of Pain

2  “Just when I have a contraction, not bad at all.”

 

Location of Pain

 

Abdomen

 

Do You Have Pain Now?

Yes

 

Pain Management Risk Assessment

Pain Assessment score:  2 using 1-10 scale 1 being minimal pain, 10 being maximum pain

 

Are you currently experiencing pain? Yes

 

 

Admission Forms Verification

Admission Forms Verification

 

Verified consent to treat in admission packet

 

Unit Orientation

Bracelet Check

Bracelets placed on client:  Hospital ID bracelet

 

Information given to: Client

 

Instructed on:

Call light

 

Emergency light in bathroom

 

Lights in room

 

Bedside controls

 

Side rail policy

 

Telephone

 

TV control

 

Meal times and snacks

 

Visiting hours

 

No-smoking policy

 

Guest information

 

Safety tips

 

Fetal monitor

 

Newborn nursery

 

Rooming in

 

Newborn identification process

 

 

Instructed on all unit policies and procedures and oriented to all room features

 

 

Summary

 

 

Risk Alerts:

Fall Risk: no

 

Pressure Sore RiskNot at Risk

Obstructive Sleep Apnea Risk: none at this time

 

 Problem List

Medical Diagnosis:

Primary Diagnosis:  Pregnancy, term

Secondary Diagnosis:  Labor

 

Nursing Diagnosis: Fluid Volume, Pain, Anxiety

 

 Active Invasive Items

IV Lines:   01:25    Left Dorsal Basilic (Hand)  Peripheral

 

Drains/Tubes: None

Basic Information

Code Status: Full code

Allergies: NKA

Isolation Status:  No  

Alerts: No

 

CLIENT MONITORING

 

Chart Time Temp Resp Pulse BP Sat% Pain  Intake   Output   Entry By
02:15 98.8 18 90 110/64 99% 2 Oral

200mL

 Void BR

1000 mL

  L Smith, RN
 03:00 98.8 18 90 112/64 2 150mL     L Smith, RN
04:00 98.6 18 90 115/68 Eyes closed       L Smith, RN
05:00 98.4 18 90 120/70 2 sips BR

400 mL

  L Smith, RN
06:00 98.6 18 86 120/66 4 IV  350 mL     L Smith, RN

 

 

 

 

Chart Time Fetal Heart Rate Decels Contraction Frequency  Intensity Cervical Dilation (cm)
02:15 120-130 External  0 Irregular about every 2-6  mild 2 cm 75%
03:00 125-130 External 0 More regular every 5  mild
04:00 Not taken   Client eye closed observed 10 mins    
05:00 130 External 0 Every 3  Mild -mod
06:00 140-150 Mild early Every 3  mod 4 cm 90%

Lab Values

 

 

  • Hemoglobin 13.0 g/dL
  • Hematocrit 40%
  • Blood Type: A-  (Completed at first OB appt)
  • GBS (group beta strep): Negative
  • Rubella: Immune
  • Gonorrhea/Chlamydia: Negative
  • Hep B: Immune

 

 

 

 

Orders per Dr Loose and Sarah Brown

Pre Delivery:

  • Routine pre delivery labs
  • Diet as tolerated, ice chips when active labor
  • IV LR @ 125 mL/hr
  • Epidural if requested after 5 cm dilated not after 8cm (primip) 7cm (multip)
  • Oxytocin augmentation 1mu/hr titrate every 15 mins until labor established: contractions q 3 mins, mod intensity, no fetal decelerations.
  • Nalbuphine 10mg IM or slow push IV q 3 hours prn do nto exceed 160mg/24hr.

 

Post Delivery:

  • Routine postpartum VS, fundal and lochia assessment
  • 30 units oxytocin in 500 LR run as needed to control bleeding begin at 125ml/hr double every 15 minutes until 500mL/hr running then notify on call provider.
  • Straight urinary cath if needed.
  • Ducosate Sodium 100mg/day
  • Witch Hazel pads
  • Acetaminophen 650mg po q6 hours prn pain
  • Saline lock after 4 hours post-delivery and lochia stable
  • D/C saline lock after RhoGAM 300 µg if required.

 

Newborn Orders

  • NRP guidelines
  • Routine newborn labs
  • VS q 15 x4, q30 x 4, q 4 hr
  • Type for Rh
  • Breastfeed on demand
  • Consult lactation consultant
  • Vitamin K 1mg IM
  • Hep B 0.5mL IM
  • Erythromycin one thin ribbon each eye

 

 

     

 

 

Get a 5 % discount on an order above $ 20
Use the following coupon code :
topwritersleague