Brenda Patton (complex) / V-sim / 5번, 6번 / Documentation Assignments / Guided Reflection Questions / 디브리핑 보고서

소개

"Brenda Patton (complex) / V-sim / 5번, 6번 / Documentation Assignments / Guided Reflection Questions / 디브리핑 보고서"에 대한 내용입니다.

목차

I. 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.
2. Document the medication(s) that you administered.
3. Document Ms. Patton’s pain during labor (severity during contractions, location, quality, interventions taken, and response to interventions) and the measures that were taken to promote her desire for a natural birth.
4. Document in situation-background-assessment-recommendation (SBAR) format your communication to the provider regarding Ms. Patton’s status and note her future care needs.
5. Document the informal patient education that you provided Ms. Patton during this scenario regarding group B streptococcus and the patient’s response to this teaching session.

II. Guided Reflection Questions
1. Opening Questions
2. Scenario Analysis Questions
3. Concluding Questions

본문내용

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.
√ 자궁 부드럽고, 약한 강도의 규칙적인 수축이 시작되었다.
수축은 약 4분 간격으로 50초 동안 지속된다.
√ FHR은 181로 간헐적인 가속과 감속증상이 없는 기준선에 있다.
√ 산모 V/S 128/76-104-39.2℃ -20-SpO2 97%

2. Document the medication(s) that you administered.
√ Lactated Ringer 용액 500mL IV bolus 60분이상
√ Promethazine 12.5mg IV
√ Acetaminophen 1000mg (1g) P.O
√ Cefazolin 2g IV

3. Document Ms. Patton’s pain during labor (severity during contractions, location, quality, interventions taken, and response to interventions) and the measures that were taken to promote her desire for a natural birth.
√ Brenda Patton의 통증은 2번 진통이 있을 정도였다.
√ NRS 2점으로 계속 통증을 호소하였다.
√ Promethazine 이 메스꺼움으로 인해 투여되었다.
√ Acetaminophen이 고열로 인해 투여되었다.

참고자료

· 없음