PATIENT CHART
Chart for Jenny Brown Simulation #3
STUDENT NAME:_______________________________
PATIENT INITALS: ___J.B._______________________
CLINICAL DATE(S): _____________________________
INSTRUCTOR: _______________
Chart Materials Jenny Brown – Simulation # 3
© National League for Nursing, 2015
1
Patient Name: Jenny Brown
Room:
DOB: 06-22-1989
Age: 23
MRN: 234-56-7891
Doctor Name: Shelley Northridge, CNM
Date Admitted:
Diagnosis: NSVD, 40 weeks; newborn Apgars 8 &
9, newborn with right-sided unilateral cleft lip and
palate. Perineum intact, no episiotomy
Patient Report (Report from nurse ending shift)
Current time: 0700, weekday morning
Situation: Jenny Brown, 23 years old, was admitted yesterday in labor. She gave birth approximately 12 hours
ago to Samantha, a 7 lb 10 oz healthy female infant with a right-sided unilateral cleft lip and palate. The vaginal
birth was uncomplicated. A neonatologist, NICU nurse, and respiratory therapist attended the delivery and
provided immediate newborn care. The boyfriend, Eric, has been here all night. He just went to get some
breakfast and will be back soon.
Background: Jenny is a Gravida 1, now Para 1, who had a spontaneous vaginal delivery without anesthesia
at 1900 hours last evening. A certified nurse midwife attended the birth and the neonatologist and NICU team
were on hand for delivery. Baby’s Apgars were 8 and 9 and she has stayed in the mom’s room ever since
delivery. Baby has a right-sided unilateral cleft lip and palate that was detected by ultrasound when mom was
18 weeks pregnant. Mom is an Iraq veteran who served in a combat zone. She had a 3-day voluntary
psychiatric hospitalization for a panic attack when she learned about the baby’s condition after the ultrasound.
She was subsequently diagnosed with PTSD. The midwife says that Jenny’s mental health status has been
stable since she started getting help at the VA, but Jenny is experiencing anxiety about her ability to care for
her newborn and has expressed concerns about losing control of her emotions while caring for the infant.
Jenny has some anemia; her hemoglobin and hematocrit on admission was 8.8 and 25%. She lost 500 ccs of
blood at delivery.
Assessment: Vital signs are stable for both mom and baby. Mom: T: 97.6; Pulse: 72 & regular; Respirations:
16 & unlabored; BP: 110/68 Baby: T: 98.8; Pulse: 120 & regular; Respirations: 40 & unlabored; BP: 60
systolic/palpated
Mom has a moderate amount of dark rubra lochia and her fundus stays firm without any problem. She has
been up to void several times and says she has no difficulty voiding. She hasn’t had a bowel movement. She
has an intact perineum but there is some bruising and swelling. She hasn’t gotten much sleep since the
delivery and expresses concern that this may cause a recurrence of the “breakdown” she experienced when
she learned of the baby’s cleft lip and palate. She expresses happiness about the baby, then sometimes starts
crying – maybe a little more than usual for a mom at this stage of postpartum. She is worried about how the
baby is feeding. She wants to breastfeed but is afraid she won’t be able to because of the baby’s lip and
palate. She is anxious about the baby’s upcoming surgeries, appearance, ability to gain weight, hearing, and
speech and language development.
Baby was a little cold initially but her blood sugar was normal and she warmed right up with some skin-to-skin
contact. She’s pretty much been “skin to skin” since she was born except for feedings. She’s passed two
Chart Materials Jenny Brown – Simulation # 3
© National League for Nursing, 2015
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meconium stools but hasn’t voided yet. The cleft lip is complete; the cleft palate extends only minimally through
the hard palate and does not affect the soft palate. We are using a special needs feeder that seems to be
working fine. She’s a little sleepy so feedings have been slow. The lactation consultant will stop by to visit later.
The Infant Feeding Team may also be contacted to do an assessment and help Jenny with breastfeeding.
Parental attachment appears to be going well. There is a lot of good eye contact between parents and between
each parent and baby. Dad helped with the first bath and when he can get the baby away from the mother, he
holds her and talks to her. They both call her by name.
Recommendation: Both mom and baby are due for assessments. Mom needs to be a little more active today
because they are planning for discharge tomorrow. She will have another hemoglobin and hematocrit and will
need to take iron supplements after she goes home. She has many questions about care of herself and baby.
She says she and the baby’s father have done a lot of studying about cleft lip and palate but she still seems
confused about details of the procedure, the recovery, or future needs for intervention. It may help if you review
what the course of treatment is likely to be. Assess her mental and emotional status, and have her complete
the Edinburgh Postpartum Depression Scale. She should follow up with her psychiatric mental health
professional at the VA sometime soon too. Both Jenny and Eric will need teaching about how to recognize
early signs of increasing emotional distress and how to manage it. Jenny has expressed concern about having
another mental break.
Provider’s Orders
Allergies: NKA
Date/Time:
Postpartum Orders
Tuesday
Admit to Acute Mother-Baby Unit
2000
Service: Women’s Health
Condition of patient: Good
1. DIET: Regular diet as tolerated
2. VITAL SIGNS: q.8h with assessment of postpartum parameters check; notify
MD for T>101.5, HR>120, heavy bleeding, alteration in mental status
3. ACTIVITY: as tolerated
4. SAFETY CHECKS: Q2h for first 24 hours, then q4h
5. LABS: Hemoglobin & hematocrit at 24 hours
6. MEDICATIONS:
a. Prenatal vitamin po q am
b. Ferrous sulfate 325 mg q am
c. Ibuprofen 650 mg po qid prn perineal pain not relieved by ibuprofen and
local treatment
7. IV ORDER: If need to start IV to administer medication, leave saline lock in
place
8. MISCELLANEOUS: Contact maxillofacial team to visit patient before discharge
Shelley Northridge, CNM
Chart Materials Jenny Brown – Simulation # 3
© National League for Nursing, 2015
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Stat Order Form
Date/Time:
STAT PHYSICIAN ORDER
Lab Data
Date/Time:
0800
Chemistries
Hematology
Urinalysis
Test:
Sodium
Potassium
Result:
137 mEq/L
4.0 mEq/L
Reference range:
135-145 mEq/L
3.5-5.2 mEq/L
Calcium
8.5 mg/dl
8.5 – 10.2 mg/dl
Carbon dioxide
26 mEq/L
20-29 mEq/L
Chloride
103 mEq/L
96-106 mEq/L
Glucose
99 mg/dl
74 -106 mg/dl
Bun
Creatinine
15 mg/dl
1.0 mg/dl
7-20 mg/dl
0.8 – 1.4 mg/dl
Hematocrit
28%
38 – 43%
Hemoglobin
8.8 g/dl
12 – 16 mg/dl
Specific gravity
1.005
1.002 – 1.030
pH
5
5–7
Leukocytes
Neg
Neg
Nitrite
Neg
Neg
Protein (mg/dL)
Neg
Neg - Trace
Glucose (mg/dL)
Neg
Neg
Ketones
Neg
Neg
Urobilinogen
(mg/dL)
Neg
Neg
Bilirubin
Neg
0.2 – 1.0 Ehr U/dl
Micro
Neg
RBCs: 0-2/HPF
WBC: 0-2/HPF
RBC Casts: 0/HPF
Chart Materials Jenny Brown – Simulation # 3
© National League for Nursing, 2015
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Medication Administration Record
Allergies: NKA
Scheduled & Routine Drugs
Date
of
Order:
Medication:
Dosage:
Route:
Frequency:
Prenatal
vitamin
Ferrous
sulfate
325 mg
Hours to
be
Given:
0900
Dates/Times
Given/Initials:
-
0900
-
PRN Medications
Date
of
Order:
Medication:
Dosage:
Route:
Frequency:
Hours to
be
Given:
Dates/Times
Given/Initials:
Ibuprofen
650 mg
po qid
prn pain
-
Hydrocodone
5-10 mg
po qid
prn perineal
pain not
relieved by
ibuprofen
and local
treatment
-
Nurse Signatures
Date/Time
Initial
Nurse Signature
Chart Materials Jenny Brown – Simulation # 3
© National League for Nursing, 2015
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Patient Name: Jenny Brown
Physician: Shelley Northride,
CNM
Age: 23
Gender: Female
Height: 5’6”
Weight: 142 lbs
Major Support: Boyfriend/partner
Eric
Phone: 555-555-5555
Eric (boyfriend) 555-555-5566
Type of Operation: None
History: G1P1
Advanced Directives: No
Diagnosis: NSVD, 40 weeks;
newborn Apgars 8 & 9, newborn
with right-sided unilateral cleft lip
and palate; intact perineum
Allergies: None known
Fall Precautions: Low
Isolation Precautions: Standard
Restraints: No
Diet: Regular
Monitoring
Vital signs – Q8h
Postpartum checks – Q8h
Medication
Oral medications
Respiratory
Social History
- Lives in own home with
boyfriend, Eric
- College student
- Parents live in another state
Consults
- Maxillofacial (cleft lip and
palate) team
Treatments
Activities of Daily Living
As tolerated, self-directed
Discharge Planning
- Consult maxillofacial team,
neonatology, pediatric surgeon –
all to visit patient before
discharge
- Home care follow-up
Race/religion: Christian
Medication brought from home:
None
Diagnostic Studies
Lab – Hemoglobin & hematocrit
24 hours postpartum
Chart Materials Jenny Brown – Simulation # 3
© National League for Nursing, 2015
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Patient Name: Baby Girl Brown
Gender: Female
Weight: 7 lb 10 oz
Length: 19”
Head Circumference: 19 cm
MRN: 345-67-8910
Doctor Name: Linda Barkus, MD
Diagnosis: NSVD, 40 weeks; Apgars 8 & 9, rightsided unilateral cleft lip and palate
Provider’s Orders: Newborn
Allergies: NKA
Date/Time:
Newborn Orders
Tuesday
Admit to Mother-Baby Unit
2000
Service: Pediatrics
Condition of patient: Good
1. NUTRITION: Use special needs feeder to ensure 90 cals/kg/day minimum; may
breastfeed. Consult lactation specialist ASAP to assist mother with pumping,
possible breastfeeding
2. VITAL SIGNS: q.4h; notify MD for unstable temp, respiratory difficulty
3. HEPATITIS PROPHYLAXIS: per unit routine based on mother’s screening
results
4. SAFETY CHECKS: Q.2h for first 24 hours, then q.4h
5. LABS: Hemoglobin & hematocrit at 24 hours; bilirubin if mother Rh- or o+
6. SPECIAL CARE: Notify maxillofacial team of birth; request craniofacial team
evaluation before discharge
7. MEDICATIONS: Erythromycin ophthalmic ointment, ½” in both eyes within one
hour following birth for prophylaxis against infection
Linda Barkus, MD
Stat Order Form
Date/Time:
STAT PHYSICIAN ORDER
Chart Materials Jenny Brown – Simulation # 3
© National League for Nursing, 2015
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Lab Data
Date/Time:
0800
Chemistries
Test:
Sodium
Result:
Reference range:
2000: 70; 2200:
80; 2400: 80
80 – 90 mg/dl
Specific gravity
1.005
1.002 – 1.030
pH
5
5–7
Leukocytes
Neg
Neg
Nitrite
Neg
Neg
Protein (mg/dL)
Neg
Neg - Trace
Glucose (mg/dL)
Neg
Neg
Ketones
Neg
Neg
Urobilinogen
(mg/dL)
Neg
Neg
Bilirubin
Neg
0.2 – 1.0 Ehr U/dl
Micro
Neg
RBCs: 0-2/HPF
WBC: 0-2/HPF
RBC Casts: 0/HPF
Potassium
Calcium
Carbon dioxide
Chloride
Glucose
Bun
Creatinine
Hematology
Hematocrit
Hemoglobin
Urinalysis
Chart Materials Jenny Brown – Simulation # 3
© National League for Nursing, 2015
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Medication Administration Record
Allergies: NKA
Scheduled & Routine Drugs
Date
of
Order:
Medication:
Dosage:
Route:
Erythromycin
opthal oint
Frequency:
Hours to
be
Given:
Once
Dates/Times
Given/Initials:
- Wednesday/
1930 DG
PRN Medications
Date
of
Order:
Medication:
Dosage:
Route:
Frequency:
Hours to
be
Given:
Dates/Times
Given/Initials:
-
Nurse Signatures
Date/Time
Initial
DG
Nurse Signature
Debbie Grey, RN
Chart Materials Jenny Brown – Simulation # 3
© National League for Nursing, 2015
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Chart Materials Jenny Brown – Simulation # 3
© National League for Nursing, 2013
10
Retrieved from http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf
Chart Materials Jenny Brown – Simulation # 3
© National League for Nursing, 2013
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Patient Name: Baby Girl Brown
Physician: Linda Barkus, MD
Diagnosis: NSVD, 40 weeks;
Apgars 8 & 9, right-sided
unilateral cleft lip and palate
Gender: Female
Length: 19”
Weight: 7 lbs 10 oz
Head Circumference: 19 cm
Major Support: Mother - Jenny
Brown; supportive biological father
involved in care - Eric
Phone: Mother 555-555-5555
Eric (father) 555-555-5566
Type of Operation: None
History: NSVD, Apgars 8, 9;
unilateral right-sided cleft lip and
palate
Advanced Directives: No
Allergies: None known
Fall Precautions: Low
Isolation Precautions: Standard
Restraints: No
Diet: Use special needs feeder
to ensure 90 cals/kg/day
minimum; may breastfeed.
Consult lactation specialist ASAP
to assist mother with pumping,
possible breastfeeding
Monitoring
Vital signs – Q8h
Medication
Respiratory
Maternal History
- G1, P1
- NSVD History PTSD, anxiety,
panic
- No medications during
pregnancy
Consults
- Maxillofacial (cleft lip and
palate) team
Treatments
Diagnostic Studies
Activities of Daily Living
Lab – Hemoglobin & Hematocrit
Routine newborn care
24 hours postpartum
Discharge Planning
- Consult maxillofacial team,
neonatology, oediatric surgeon –
all to visit family before
discharge
- Home care follow-up
Chart Materials Jenny Brown – Simulation # 3
© National League for Nursing, 2013
12