SBAR - Olivia Jones.docx - SBAR - OLIVIA JONES Situation-...

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SBAR – OLIVIA JONES Situation- Ms. Olivia Jones, 23 years old African American, she in 36 weeks of gestation, G1P0. She is experiencing elevated blood pressure 170/102, complaining of a headache, epigastric pain and nausea. She was admitted due to her severe preeclampsia symptoms.I’ve given her 10L oxygen and lactated ringer 125ml/hr, she reports no contractions and FHR is 150bmp, she is conscious but hyper reflexive +4 with positive clonus and has pitting edema +3. Background-Ms. Jones pregnancy has been pregnancy been normal until her prenatal routine check up around 30 weeks. It was from moderate to high blood pressure, 156/91 mm Hg. There was a sign of mild preeclampsia and proteinuria. Ms. Jones has been encouraged to reduced
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Unformatted text preview:activity, bed rest and reduce stress at home. Today at her visit the symptoms is increasing that result of her admission. Ms. Jones gain weight of 3 lbs from last week visit. Assessment- Ms. Jones pain - 4/10. Vital Signs BP 173/103mmHg, 170/101 mmHg, 168/103mmHg. P 114. 116. R23. Temp 37 C. SpO2 95%. Ketones and glucose are negative, puffiness in her facial, dependent edema +2It is +4 for protein dipstick. Fetal Heart rate: 168, 166, 162,161, 158, 151, 153 . Unresolved headache Recommendation: Monitoring patient for severe preeclampsia, instruct patient for bed rest, reduced activity and prepare for IV antihypertensives. Do you want to start and order and put her on magnesium sulphate?