M
CONCEPT MAP WORKSHEET
DESCRIBE DISEASE PROCESS AFFECTING PATIENT
(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
The disease process affecting the patient is shoulder dystocia. Shoulder dystocia occurs when there is
impaction of the anterior fetal shoulder behind the maternal pubic symphysis, or impaction of the
posterior shoulder on the sacral promontory. A delay in delivery of the fetal shoulders leads to hypoxia
in the fetus, proportional to the time delay to complete delivery. (aafp, 2029) Labor induction also
known as inducing labor is the stimulation of uterine contractions during pregnancy before labor
begins on its own to achieve a vaginal birth. A health care provider might recommend labor induction
for various reasons, primarily when there's concern for a mother's health or a baby's health (mayor
clinic, 2020)
DIAGNOSTIC TESTS
(REASON FOR TEST AND RESULTS)
-
CBC – WBC show if there
is any infections present
Blood type – in case blood
needs to be given
Rh type
Urinalysis
HIV screening
ANTICIPATED PHYSICAL
FINDINGS
PATIENT INFORMATION
-
Amelia Sung
Allergies: Shellfish
Gender Female
DOB 7/11/XX
Age 36 Years
Height 61.8 in
Weight 183 lb.
Adm On
02/12/2021
-
-
Turtle sign present when
delivering head
Excessive weight gain
Abnormal fetal
presentation
Use of epidural analgesia
Failure to progress
Fatigue
Early decelerations
since she started
ANTICIPATED NURSING INTERVENTIONS
-
Epidural Anesthesia Via Catheter infusion at 10 mL/hr.
Complete blood count
Non-reassuring fetal HR
BP q1 hour x 2 than Q 4 hours
Temp, HR, RR Q1 hour
Deep tendon reflexes Q4 hours
Continuous pulse oximetry
Continuous external fetal monitoring
Head to toe assessment Q4
Oxygen 10L/min per rebreather mask for non-reassuring fetal heart rate
Vaginal exam
Lactated Ringer’s
vSim ISBAR ACTIVITY
INTRODUCTION
STUDENT WORKSHEET
Hello, my name is . I am a student nurse at Nova Southeastern
University working on the labor and delivery floor.
Your name, position (RN), unit you are
working on
SITUATION
Patient’s name, age, specific reason for visit
BACKGROUND
Patient’s primary diagnosis, date of
admission, current orders for patient
ASSESSMENT
Current pertinent assessment data using head
to toe approach, pertinent diagnostics, vital
signs
RECOMMENDATION
I am calling in regard to a patient named Amelia Sung, A 32-year-old
female, G2P1 (L1) at 39 weeks of gestation, who was admitted 24
hours ago for induction of labor.
Her primary diagnosis is labor induction secondary to shoulder
dystocia. Patient was admitted 02/12/2021. Current orders for patient
include Epidural Anesthesia Via Catheter infusion at 10 mL/hr.,
Complete blood count, Non-reassuring fetal HR, BP q1 hour x 2 than
Q 4 hours, Temp, HR, RR Q1 hour, Deep tendon reflexes Q4 hours,
Continuous pulse oximetry, Continuous external fetal monitoring,
Head to toe assessment Q4, Oxygen 10L/min per rebreather mask for
non-reassuring fetal heart rate, Vaginal exam, Lactated Ringer’s
Upon admission patient presented with Heart rate: 91. Pulse: Present.
Blood pressure: 137/79 mmHg. Respiration: 18. Conscious state:
Appropriate. SpO2: 97%. Temp: 37 C. EFM: Baseline. Fetal heart
rate: 129. Patient is breathing at 21 breaths per minute. The chest is
moving equally. There is normal elasticity of the skin. Her color is
normal, and she is not sweating. Examined the patient abdomen and
pelvis. Leopold maneuvers were performed. The fetus is in
longitudinal lie, in vertex presentation. There is normal elasticity of the
skin. She appears flushed and her skin is warm and dry. The breath
sounds are clear and equal bilaterally. There were regular heart sounds
without murmurs. Normal bowel sounds were heard. Palpated the
uterus for contractions. The uterus tone was soft between contractions.
Regular contractions with strong intensity had started. Contractions
were approximately 2 minutes apart and lasting 80 seconds. A bolus of
500 mL of lactated Ringer solution IV, given over 60 minutes. The
deep tendon reflexes were normal. Graded to +2. Gave the patient
100% oxygen from a nonrebreathing mask. Applied suprapubic
pressure. Baby shoulder was delivered.
Continue to assist the mother into the third stage of labor. Additional
Any orders or recommendations you mayhave
for this patient
assessment of the baby is needed.
PHARM-4-FUN PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION: Lactated Ringer
CLASSIFICATION: Sodium Chloride
PROTOTYPE: Lactated Ringer
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
A bolus of 500 mL of lactated Ringer solution IV, given over 60 minutes
PURPOSE FOR TAKING THIS MEDICATION
Replaces sodium and chloride and maintains levels.
PATIENT EDUCATION WHILE TAKING THIS MEDICATION


Explain use and administration of drug to patient and family.
Tell patient to report adverse reactions promptly.
Date:
Initials:
AS
Assigned vSim: Amelia slug
Student Name:
Diagnosis: Labor
induction due to
gestational diabetes
HCP: Jeff smith
IsolatioN
standard
Age:36
M/F:F
Length of Stay: 1 days
Allergies: shell fish
39 weeks
Gestational age:
IV Type
lactated
ringer,
oxytocin
Location: left
arm
Fluid/Rate: 125 mL/hr, oxytocin
(30 units in 500 mL normal
saline) is running at 20 mU/min
(20 mL/hr).
Critical Labs: no critical lab
Consults Needed: doula,
midwife,NICU
Code Status:full
Why is your patient in the hospital (Answer in your own words and include the History of present Illness):
Amelia Sung is a 36 year old Filipino female, G2P1 at 39 weeks gestation, who is admitted for induction of labor and gestational diabetes. During labor and delivery
patient was diagnosed with shoulder dystocia
Health History/Comorbidities (that relate to this hospitalization): no previous health history
Shift Goals/ Patient Education Needs:
1. tell patient what a shoulder
dystocia and why it happened
2. Educate the patient on what is happening next and ever steps the doctor will take
3.medication education and the reason for taking it
Path to Discharge: shoulder dystocia can be relieved with the McRoberts maneuver and suprapubic pressure and the baby can be delivered safely and healthy
Path to Death or Injury: the mother can suffer from laceration and the baby can suffer with brachial plexus injury
Alerts:
What are you on alert for with this patient? (Signs & Symptoms)
1. Non reassuring fetal heart rate
Management of Care: What needs to be done for this Patient Today?
1. Head to toe assessment and vital signs
2.
Failure of restitution
3.
Turtle sign
What Assessments will focus on for this patient?
(How will I identify the above signs &Symptoms?)
2.
Deep tendon reflexes
3.
Encourage and support patient
4.
Stop oxytocin infusion and administer 500 mL bolus lactated
ringer
1.
Head to toe assessment
2.
Monitor heart rate, blood pressure , temperature, and oxygen level
3.
Monitor fetal heart rate
4.
frequently monitoring cervical dilation and effacement, uterine contractions, and
fetal descent
5.
Lung and heart assessment
6.
Apply McRobert Maneuver and Suprapubic pressure
7.
Monitor fetal heart rate
8.
Call for help
List Complications that may occur related to dx, procedure, comorbidities:
1.
Cervicovaginal lacerations
4.
Postpartum hemorrhage
5.
Brachial plexus
6. Clavicle fracture
What nursing or medical interventions may prevent the above Alert or complications?
1. Call for help
2. McRoberts maneuver
3.
Evaluate for episiotomy
4.
Suprapubic pressure
Priorities for Managing the Patient’s Care Today
1. Call for help
2. Vitals Signs and head to toe assessment
3. Lung and heart assessment
4.
Stop oxytocin infusion and administer 500 mL bolus lactated
ringer
5.
Apply McRobert Maneuver and Suprapubic pressure
What aspects of the patient care can be Delegated and who can do it?
Nurse aide can take the patient vital signs
Reflection question
Maternity Case 6: Amelia Sung (Complex)
Guided Reflection Questions
Opening Questions
How did the simulated experience of Amelia Sung’s case make you feel?
This time I felt more comfortable doing the simulation
Describe the actions you felt went well in this scenario.
 Assessing the patient and prioritizing interventions related to non-reassuring FHR.
 Calling the charge nurse and NICU team and assisting the provider with the delivery.
Scenario Analysis Questions
1EBP What risk factors specific to shoulder dystocia were identified in Amelia Sung’s case?
- Prolonged second stage of labor, estimated fetal weight of 4000 gm, maternal diabetes
(macrosomia),
PCC/I Prioritize your nursing actions for Amelia Sung based on your assessment
Stay calm and immediately call for additional assistance (extra nurses, charge nurse, NICU
team).
- Change the mom’s position into McRoberts position.
- Apply suprapubic pressure to help push the anterior shoulder under the symphysis pubis.
- Encourage the patient to push during contractions to help accomplish the birth
- Provide the patient encouragement and support to reduce anxiety.
- Document the time the head emerges, time maneuvers are implemented, and the time
body/shoulder emerge.
- Hand the baby to the charge nurse for physical examination for any fractures of the clavicle,
brachial plexus injuries and asphyxia.
EBPList potential problems for Amelia Sung and her baby related to the shoulder dystocia.
Fetal injury can result from asphyxia related to delay in completing the birth or by trauma from
the maneuvers used to accomplish the birth.
- Permanent fetal damage such as brachial plexus can result from intrauterine forces during
second stage of labor.
- Maternal postpartum hemorrhage and rectal injuries.
T&C List the interprofessional health care team that should be involved in Amelia Sung’s case.
- Health care provider, NICU team, charge nurse, extra nurses, anesthesia specialist.
S/QI/I Consider what points might be included in a safety checklist for shoulder dystocia.
- Prompt action by the nurse must ensue upon the announcement of shoulder dystocia.
- time of delivery of the head and delivery of the body should be less than 6 minutes to prevent
irreversible fetal damage.
- Having the NICU team and charge nurse ready to allow for immediate interventions and save
the baby.
Concluding Questions
Reflecting on Amelia Sung’s case, were there any actions you would do differently? Explain.
- Nothing, all the actions in this simulation were effective and needed.
Describe how you would apply the knowledge and skills that you obtained in Amelia Sung’s case to an
actual patient care situation.
- I learned a lot from this case scenario about shoulder dystocia and the assessment findings that
would indicate this problem and the interventions needed to prevent harm for the baby and the
mom. I feel I’m more confident about this complication now after doing this case study that I
can prioritize care for a real patient going through this knowing how to act quickly and stay calm
at the same time
Rubric for Grading vSim Clinical Worksheet
5
Patient Information:
3
Why patient is in the hospital,
History of present Illness, Past
Medical/Surgical History,
Comorbidity Factors
Patient Education/Goals:
Shift Goals, Patient Education
Needs
Disease Progression:
Pathway to Death or Injury
Pathway to Health
AACIP:
Alerts, Assessments,
Complications, Interventions
and Prevention
Nursing Care Plan:
Management of Care, Priorities
for Patient Care, Delegation
0
Three listed areas completed OR
documented areas 75% complete.
Less than three listed areas completed
OR documented areas less than 50%
completed.
Patient information area blank.
100% of HPI, Past Medical/Surgical
History and Comorbidity Factors
completed with thorough, relevant
information.
75% of HPI, Past Medical/Surgical History
and Comorbidity Factors completed.
Information relevant to scenario.
50% of HPI, Past Medical/Surgical
History and Comorbidity Factors
completed. Information basic and lacks
relevancy.
25% of HPI, Past Medical/Surgical
History and Comorbidity Factors
completed. Information not relevant,
or content areas left blank,
Thorough and detailed patient education.
Patient shift. goals are SMART, relevant,
and detailed goals. 100% of worksheet
area is complete.
Provides patient education but lacks
thoroughness or details. Patient shift
goals missing 1-2 components of SMART
goals. 75% of information needed for
worksheet area present.
Patient education lacks thoroughness
and details. Patient shift goals missing 3
– 4 components of SMART goals. 50%
of the information needed for worksheet
area present.
Pathway to death and health is identified
with detail. Information is concise, relevant,
accurate and portraits appropriate
timeframe for occurrence. 100% of the
information needed for worksheet present.
Pathway to death and health is identified.
Information is relevant and accurate.
Missing timeframe for occurrence. 75% of
information needed for worksheet area
present.
Missing over 50% of needed information
for worksheet area present. Pathway to
death and health identified but content
either not relevant or accurate for
situation present in scenario.
Missing patient education and/or
patient shift goals. Patient shift
goals lack all components of
SMART goals. 25% of the
information needed for worksheet
area present.
Pathway to death and health
contains information not relevant or
accurate to the scenario or section
left blank.
Alerts, Assessments, Complications and
Interventions/Preventions identified
thoroughly. Answers relevant to scenario.
100% of the information needed is present.
Alerts, Assessments, Complications and
Interventions/Preventions identified. Most
answers relevant to scenario. 75% of the
information needed for worksheet area
present.
Missing 2 – 3 areas on worksheet.
Answers not relevant to scenario. 50%
of the information needed is present.
Missing 4 or more areas on
worksheet. Answers not relevant to
scenario. 25% of the information
needed for worksheet area is
present.
Management of Care relevant to case
scenario and detailed. Priorities for
scenario identified. Identifies all aspects of
care that can be delegated and identifies
appropriate personnel to delegate activities
to. Answers detailed, Critical thinking
evident.
Management of Care, Priorities or
delegation sections relevant to scenario.
Answers generic to situation. Some
evidence of critical thinking present.
Missing relevant data in one or more
categories (management of care,
prioritization, delegation). Answers basic
without detail. Little to no evidence of
critical thinking present.
Information provided not relevant to
scenario. Answers are basic
without detail. No evidence of
critical thinking. Missing answers in
one or more area.
Demographics, Diagnosis,
Allergies, Provider, Consults,
Isolation, Fall Risk, Intravenous
Therapy, Critical Labs, Services
and Needed Consults
Medical History:
1
All documented areas 100% complete and
provide thorough information.
TOTAL POINTS
vSim Grading Rubric for Pharm4Fun, ISBAR, and Concept Map Worksheets
Criteria
5 Points
4 Points
3 Points
2 Points
Content
Knowledge
-Follows all requirements for
the assignment.
-Conveys well-rounded
knowledge of the topic.
-Content well organized,
logical.
-Easy to read and understand
throughout all of worksheet.
-Follows all requirements
for the assignment.
-Major points of topic are
mostly covered in the
required assignment areas.
-Content organized, logical
flow.
-Easy to read and
understand through most
of worksheet.
-Knowledge of topic is
partially covered.
-Key information is missing
from 2 or more assignment
areas.
-Worksheet difficult to follow
in two or more areas.
-Information is incomplete in
two or more areas.
Critical
Thinking
-Concisely explains each
content area.
-Analyzes information,
connects data points to
provide accurate, concise
information.
-Scholarly work.
-Explains each content
area.
-Presents information
about the topic.
-Some analysis, insight
present, some data points
threaded together.
-Scholarly work.
-Major aspects of the content
areas are presented, but
content lacks insight and
analysis.
-Few data points connected
to provide information.
-Few aspects of the
content areas presented.
Few insights presented,
lacking analysis.
-Data points not connected
to information provided.
-Little understanding
gained from information
presented.
-Information is basic.
-No aspects of the
content present in the
worksheet.
-Lacks insight, analysis,
and conclusions.
-No understanding from
the content presented.
Writing
Composition
(Spelling,
Grammar,
Sentence
Structure)
-An occasional spelling error
present.
-Grammar, readability, and
sentence structure is error
free.
-Some minor errors (1-3
errors) with spelling,
grammar and/or sentence
structure, not consistent
throughout worksheet.
-Errors do not interfere
with the readability or
comprehension of
information.
-Frequent errors (4-5 errors)
with spelling, grammar and/or
sentence structure.
-Errors effect ability to
comprehend information
present on worksheet and
readability.
-Numerous errors (5-6
errors) with spelling,
grammar and/or
sentence structure
throughout worksheet.
-Difficult to understand
information presented due
to numerous errors.
-Excessive errors (>6
errors) occur with
spelling, grammar
and/or sentence
structure, throughout
worksheet.
-Unable to understand
information presented in
the worksheet.
- Knowledge of topic is
general in more than
three areas of the
worksheet.
- 1 or more areas of
worksheet le�blank.
-Content unorganized
throughout worksheet.
-Difficult to understand
content of paper.
1 point
-Knowledge of topic is
general throughout
entire worksheet, and/or
does not cover all the
required assignment
areas.
-Two or more areas le�
blank on worksheet.
-Unable to follow flow of
worksheet.
Total Points:
Total Points
Total Points Rubric for All Assignments
NOTE: Students must earn 80 points or higher to attain passing status for clinical hours
Worksheet/Activity
Clinical Worksheet
Concept Map
ISBAR
Pharm4Fun
Reviewed
Suggested Readings
Pre/Post Simulation
Quiz
vSim Patient care at
100%
DocuCare Charting
Reflection &
Lasater Clinical
Worksheet/Activity Totals Rubric
Points Available
30 points
(Points from Rubric for Grading vSim
Clinical Worksheet)
15 Points
(Points from vSim Grading Rubric
for Pharm4Fun, ISBAR, and Concept
Map Worksheets)
15 Points
(Points from vSim Grading Rubric
for Pharm4Fun, ISBAR, and Concept
Map Worksheets)
15 Points
(Points from vSim Grading Rubric
for Pharm4Fun, ISBAR, and Concept
Map Worksheets)
5
5
5
5
5
Points Earned
Judgement Rubric
Completed
80 points or higher is passing
Exemplary = 4 point
Total Points Earned:
Pass or Fail:
Scoring:
Accomplished = 3 points
Beginning = 1 point
Noticing:
Score: vSim 1
Focused Observation:
Recognizing Deviations from
Expected Patterns:
Information Seeking:
Score: vSim 2
EADB
E
EADB
EADB
E
E
Total for category:
Developing = 2 points
Score: vSim 2
12
Interpreting:
E
Prioritizing Data:
Making Sense of Data:
EADB
EADB
E
8
Total for category:
Responding:
Calm, Confident Manner:
EADB
Clear Communication:
EADB
Well-Planned Intervention/Flexibility:
EADB
Being Skillful
EADB
E
E
E
E
16
Total for category:
Reflecting:
Evaluation/Self-Analysis:
EADB
Commitment to Improvement: E A D B
E
E
Total for category:
8