Case Overview Hannah Question & Answer Guide (With Explanation)
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Original Question
Case Overview: Hannah Wilder is a 23-year-old G1 P0 at 40 3/7 weeks who has experienced spontaneous rupture of membranes. She is Group Beta Strep positive and as labor has continued, she has developed a fever and the fetus is tachycardic. DocuCare Activity/Assignment Prep: Review the Clinical Decision Support Tool (Green Lippincott Advisor links) provided throughout your patient’s chart: Labor and Birth Fetal Monitoring, Internal Oxytocin Group B Streptococcus care during labor Penicillin G potassium Acetaminophen O’Meara, A. Hannah Wilder. Maternity, newborn, and women’s health nursing: A case-based approach. Philadelphia, PA: Wolters Kluwer. Review chart including Patient Information, Maternity, Notes, Assessments, Diagnostics, Vital Signs, and Orders Activities/Assignments: Part One: Clinical Judgment Activity Assignment 1.1: Using the fetal monitoring strip below and the additional information, enter data into Mrs. Wilder’s electronic health record utilizing the Maternity tab and subcategory Labor Vital Signs (Recognize & Analyze Cues/Assessing). Maternity: Labor Vital Signs: Resting supine in the birthing bed External uterine and fetal monitors in place Pitocin at 7mu/min Vital Signs: Temp 102.8° F oral, HR 110, RR 22, BP 102/60, Sats 97% on room air Part Two: Clinical Judgment Activity EST TIME: 30 – 60 MIN After reviewing Ms. Wilder’s chart, identify the relevant data related to the patient situation. Analyze the data, ask yourself these questions: What do you notice? (Recognizing Cues/Assessing) What does it make you think? (Analyzing Cues/Diagnosing) What do you think should be done? (Prioritize Hypotheses & Generate Solutions/Planning) What additional information or orders do you need? (Generate Solutions/Planning) Assignment 2.1: Document the answers to the questions in the Notes section > Nursing Note-Progress Note Part Three: Clinical Judgment Activity EST TIME: 15 MIN Review the patient’s Medication Administration Record. Use the information you have gathered in Part 1 and 2 to determine which medications you would administer. Assignment 3.1: Administer the medications you feel are a priority for this patient (Take Action/Implementing). Utilize the principles of medication administration, Rights of Medication Administration, and Three Checks when documenting the administration of the medications. Provide rationale for administering the specific medication in the Administration Notes (Analyzing Cues & Generate Solutions). Part Four: You alert the OB provider via telephone to the current status of your patient. You relay that the patient is contracting every 4 minutes, moderate to palpation, Pitocin is at 7mu/min, fetal heart rate is 170 with minimal variability, no accelerations or decelerations, and the patient remains febrile. The physician provides the following telephone orders: Gentamicin 2mg/kg IV followed by 1.5mg/kg IV every 8 hours Increase Pitocin by 2mu/min till contractions every 2 minutes Temperature every hour, alert OB Provider if temperature > 103 oral Assignment 4.1: Enter the physician orders in the Orders tab. Administer the ordered medications in the patient’s Medication Administration Record. Document the increase in Pitocin under Maternity > Labor Vital Signs > Other interventions. Debriefing Questions: Following completion of the above activities, answer the debrief questions and submit to Canvas. How did you feel while completing this assignment? What went well during this activity? What did you find challenging? What risk factors related to intrapartum infection are present in Ms. Wilder’s health record? What were the priority interventions for Ms. Wilder? What order would you perform the interventions? What effect could Ms. Wilder’s risk factors and intrapartum concerns have on the neonate?
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