Magnesium Note Template
| S: |
Need to ask overall how patient is
feeling, any shortness of breath, headache, visual
disturbances. Also if patient on MgSO4 for PTL,
then ask about contractions, vaginal bleeding or
loss of fluid. If on MgSO4 for preeclampsia need
to ask also about nausea or vomiting , and RUQ pain.
|
| O: |
Vital signs (especially important
if on MgSO4 for preeclampsia)
Fetal
heart tones, contractions (if any)
Urine output is critical. MgSO4
should cause diuresis. Comment on UOP
>
Over certain period of time (i.e., 400cc over last
4 hours)
General Appearance:
can she answer your questions or is too lethargic
Cardiovascular:
Lungs:
important to assess for clear (MgSO4 can cause pulmonary
edema)
Abdomen:
Extremities:
extremely important to assess DTRs in patellar and
achilles
Assess for clonus
Labs: Mg level every 6 hours, and
if preeclamptic, check for PIH labs
|
| A/P: |
__ year old G_P_ at __ gestational age, on MgSO4
for PTL or Preeclampsia
No signs/symptoms of Mg toxicity (if there are none).
Discuss any other plan
Previously made for this patient (i.e., B-methasone,
antibiotics, etc.)
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