Documentation Assignments 1. Document your initial assessment data of Ms. Patton, including uterine activity (frequency and duration), fetal heart rate (FHR) activity (baseline FHR, long-term variability, accelerations, and decelerations), vaginal discharge, and maternal vital signs. - After arriving at the patient’s side, I introduced myself to patient and washed my hands. I identified patient and ask her if she had any allergies. I then checked patient’s vital signs. Ms. Patton’s vital signs: HR: 88, Pulse: Present, BP 117/70 mm Hg, Respirations: 20, normal breathing and chest moving equally. Ms. Patton is in an appropriate conscious state, and her SpO2 is 97%. Her temperature is 99 F. EFM showed baseline, and fetal heart rate was 141. -Examination: Examined Ms. Patton’s head: No obvious airway obstruction and there is normal elasticity of the skin. Her color is normal and she is not sweating. Next I examined Ms. Patton’s chest. She is breathing at 20 breaths per minute and her chest moving equally. Normal elasticity of the skin and skin color is normal. She is not sweating. Ms. Patton’s arms were normal elasticity and her skin color was normal and she was not sweating. There was nothing else to examine on her arms. Ms. Patton’s abdomen and pelvis were examined next. Leopold’s maneuvers were performed and the fetus is in longitudinal lie, in vertex presentation. Nothing to be examined on Ms. Patton’s legs. No pitting edema and her deep tendon reflexes were normal, 2+. -Ms. Patton’s uterine activity includes a ruptured membrane earlier today, with clear amniotic fluid. AmniSure was +. Vaginal exam reveals 50?facement of cervix, cervical dilation 4 cm, and fetus at -2 station. Ms. Patton reports pain 2/10 and said the pain starts in between contractions. Palpated the uterus for contractions. It was soft between contractions and regular contractions with moderate intensity had started. Contractions were approximately 4 minutes apart and lasted 50 seconds. The fetal heart rate was assessed using a doptone device. 2. Document the medication(s) that you administered. -Penicillin 5 million units IVPB (piggyback). -Promethazine 12.5 mg IVPB (piggyback) every 4 hours PRN (for nausea/vomiting). 3. Document Ms. Patton’s pain during labor (severity during contractions, location, quality, interventionstaken, and response to interventions) and the measuresthat were taken to promote her desire for a natural birth. - Uterus wassoft between contractions and regular contractions with moderate intensity had started. Contractions were approximately 4 minutes apart and lasted 50 seconds. The fetal heart rate was assessed using a doptone device. Ms. Patton reported 2/10 pain in her lower abdomen. The interventionstaken were calming Ms. Patton and her significant other as well as educating them, and calling the provider. The measuresthat were taken to promote her desire for a natural birth included not inserting an epidural and calling the provider for any more information on what he recommends. 4. Document your handoffreportin the situation-background-assessment-recommendation (SBAR) format to communicate what further care Ms. Patton needs. -Brenda Patton, an 18-year old Caucasian female, G1P0 at 38 2/7 weeks of gestation is admitted to the labor and birthing unit for labor assessment. She states her water may have broken earlier this morning and she thinks she is in labor. AmniSure was +. Vaginal exam reveals 50?facement of cervix, cervical dilation 4 cm, and fetus at -2 station. Her boyfriend is present and Ms. Patton’s mother was called earlier by Ms. Patton to inform her of her admission. The provider has been notified and prenatal records have been pulled. The lab report indicates that the patient’s group B strep vaginorectal cultyre taken at 36 weeks was positive. The patient wishes to have a natural birth without medication. Admission intrapartum orders have been initiated, initial labs have been drawen, and a saline lock has been placed. -Ms. Patton’s vital signs: HR: 88, Pulse: Present, BP 117/70 mm Hg, Respirations: 20, normal breathing and chest moving equally. Ms. Patton is in an appropriate conscious state, and her SpO2 is 97%. Her temperature is 99 F. EFM showed baseline, and fetal heart rate was 141. - Examined Ms. Patton’s head: No obvious airway obstruction and there is normal elasticity of the skin. Her color is normal and she is not sweating. Next I examined Ms. Patton’s chest. She is breathing at 20 breaths per minute and her chest moving equally. Normal elasticity of the skin and skin color is normal. She is not sweating. Ms. Patton’s arms were normal elasticity and her skin color was normal and she was not sweating. There was nothing else to examine on her arms. Ms. Patton’s abdomen and pelvis were examined next. Leopold’s maneuvers were performed and the fetus is in longitudinal lie, in vertex presentation. Nothing to be examined on Ms. Patton’s legs. No pitting edema and her deep tendon reflexes were normal, 2+. -Medication: Ms. Patton received Penicillin 5 million units IVPB (piggyback). Promethazine 12.5 mg IVPB (piggyback) every 4 hours PRN (for nausea/vomiting). -Ms. Patton and her boyfriend were educated on the following: -“We can see that you are in active labor. We will be monitoring you and will do some diagnostic tests to make sure everything is fine with you and your baby.” - Group B Streptococcal continues to be one of the leading infections of infant mortality abd morbidity in the US. The primary risk factor is maternal intrapartum colonization, and your screening