Sharon Williams

Maternity Case 5: Fatime Sanogo

Documentation Assignments

1. Document your initial assessment data for Ms. Sanogo, including

vital signs, fundal assessment (consistency, position, location),
lochia assessment (amount, color, odor, consistency), and pain
(location, quality, severity).
 Temperature 38 C; HR <50, >100; RR <12, >24, BP sys <90,
>140; dia >90, Sp01 <94%
 Lochia heavy or patient passing clots
 Trendelenburg position
 Vital signs Q 4 hours, than Q 8 hours thereafter if vital signs
within normal parameters. Fundal, bladder, lochia and
perineal checks Q 4 hours x 24 hours, then Q 8 hours.
Assess pain level using visual analog scale (VAS) Q 4 hours
and PRN, assess IV.

2. Write the situation-background-assessment-recommendation

(SBAR) communications you would use to update the provider on
Ms. Sanogo’s status after your first encounter with her.
 S – Fatime Sanogo 23 year old female, admission diagnose:
Indruciton of labor secondary to postdates. She delivered a
vigorus female infant at 0605 hours with Apgar scores of 9
and 9 and weight of 4,082 g (9 lb 0oz). The patient

From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
 contracted a second-degree perineal laceration during
delivery; this has been repaired. Re-assess patient’s
breathing, pain level, bleeding/lochia, and bladder.

3. Document the medication(s) you administered to Ms. Sanogo and

evaluate each drug’s effectiveness.
 Butorphanol tartrate 2 mg IV PRN for pain. Do not repeat.
 Ibuprofen 800 mg Q 8 hours not to exceed 2400 mg in 24
hours.
 Lactated Ringer 500 mg IV bolus
 Oxyocin (Pitocin) 500 mL

4. Document the sequence of events during the simulation (i.e., vital

signs, assessment findings, blood loss, nursing interventions, and
patient response).
 First step – Doctor evacation of the retained tissue from the
uterus. Then oxytocin is administered to help maintain
uterine contraction.
 Blood loss of 800 mL in 25 minutes; pulse tachycardia and
week; pain scale 5 out of 10.
 Due to the increased blood volume of pregnancy, vital signs
and urine output don’t reflect bleeding until approximately
1800 mL (60.9 oz) of blood has been lost. Therefore, early
estimates of the degree of blood loss are based on
observation or weighting pads to quantify blood loss.

5. Ms. Sanogo is going to be taken back to labor and delivery for a

manual examination. Write the transfer note.

From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
 Ms. Sango is being transport back to labor and delivery for
manual examinatiaon. Monitor the patient for risk of
hemorrhage.

From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.