Clinical Worksheet Temp.docx - Date Initials BP Age 18y.o...

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Clinical Worksheet Date: 6/12/20 Name: Sasha Velazquez Assigned vSim: Brenda Patton Initials: BP Age: 18y.o M/F: F Code: Full Diagnosis: Rupture of membranes/Labor Assessment Length of Stay: 1 day Allergies: NKDA HCP: N/A Consults: N/A Isolation: Standard Fall Risk: Mild Transfer: N/A IV Type: Peripheral Location: L forearm Fluid rate: 5million IU IVPB Critical Labs: Vagino- rectal Group B Strep Culture: Positive Other Services: N/A Consults Needed: N/A Why is your patient in the hospital? (Answer in your own words and include Hx of present illness): Patient is currently in labor. Patient states her water broke early this morning. Health History/Comorbities (that relate to this hospitalization) - G1P0 38 2/7 weeks Shift Goals/Patient Education Needs: 1. Assess patient’s vital signs q2-4hr. 2. Perform head to toe assessment. 3. Administer penicillin for GBS as ordered. 4. Educate patient on GBS and her treatment plan. 5. Monitor fetal heart rate.

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