NUR 4130 Carla Hernandez Vsim Nursing/NUR 4130 Carla Hernandez Vsim Nursing( Complete Solution Rated A)

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CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) PATIENT INFORMATION ANTICIPA... TED PHYSICAL FINDINGS Vaginal exam CBC Carla Hernandez 32 year old Hispanic Female G2P1 (L1) at 39 5/7 weeks gestation Low lying placenta ANTICIPATED NURSING INTERVENTIONS With gloved hand, insert hands into vagina to relieve pressure of umbilical cord .rolapse Put the patient into Trendelenburg position Provide oxygen therapy for bradycardic fetal heartbeart Lactated ringers bolus vSim ISBAR ACTIVITY STUDENT WORKSHEET INTRODUCTION Karen Brito, RN, labor and birthing room Your name, position (RN), unit you are working on SITUATION Carla Hernandez, 32, umbilical cord prolapse Patient’s name, age, specific reason for visit BACKGROUND Umbilical cord prolapse Date of admission: Current orders: Vaginal exam, CBC STAT, Lactated Ringers 500mL IV bolus (for nonreassuring fetal heart rate) Oxygen 10L/min nonrebreather mask Administered 0.25 mg of terbutaline subcutaneously. Patient’s primary diagnosis, date of admission, current orders for patient ASSESSMENT A/ Pt identified as Carla Hernandez, no known allergies . Pt status - Heart rate: 90. Pulse: Present.Blood pressure: 137/81 mmHg. Respiration: 16. Conscious state: Appropriate. SpO2: 97%. Temp:37 C. EFM: Baseline. Fetal heart rate: 89, presenting bradycardia, recurrent late decelerations, declining variable deceleration and showing sinusoidal pattern (Category III: abnormal FHR). Pt was given 10L oxygen with nonrebreathing mask and administered and 500ml of lactated Ringer was given IV bolus. FHR dropped to 50. Vaginal exam was performed showing umbilical cord prolapse. The presenting part was pushed away from the umbilical cord to alleviate pressure using sterile gloves. The charge nurse and provider were called, pt was schedule for C/S and 0.25mg of terbutaline were administer. FHR improved to 105. [Show More]

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