University:
West Coast University
Course:
NURS 110 | Introduction to Professional Nursing
Academic year:

2022
Views:

37

Pages:

3
Author:

ddifenwadbyx

I-SBAR for Direct Patient Care Documentation - Antepartum/Intrapartum I - Introduce Yourself Your Name: Your Title: Student nurse Reason for being there: Patient care DOB: Patient Initials: M.G EDC: N/A LMP: 5/12 Age: 27 G/T/P/A: / / / L Other: Gast. Age: 33 1/7 weeks S - Situation ☐ Singleton ☐ Twin ☐ Other Reason for Admit: dysuria & generalized malaise w/ possible preterm labor Fetal Movement: Present ☐ Not Present Membrane Status: Ruptured ☐ Intact ☐ Ruptured Date: 8/16 Time: 1000 Fluid: minimal minimal blood, pink B - Background Previous Pregnancies: N/A Year Type of Delivery Labor Length Complications Current Pregnancy - Prenatal Care: ☐ Yes ☐ No GBS Status: ☐ Positive ☐ Negative Labs: UA CBC CMP Breast Feeding: ☐ Yes ☐ No Complications: dysuria, frequent urination Family Support: N/A Past Medical History: N/A Home Medications: N/A Vital Signs Temp B/P HR RR SpO2 Pain FHTS 36.4(12:01:25) 122/82 90 16 97% 3 08:00 36.4(11:12:15) 110/72 88 14 96% 3 135 09:00 A - Assessment Labor Status: complete prep @ onset 8:30 & 08:00 Stage/Phase: ACTIVE Vaginal exam: 3 / 74 / 1.2cm Blood/Fluid: bloody/pink Planned method of delivery: Vaginal ☐ Original ☐ C-section Contraction pattern: frequency: Duration: Strength: Labor progress: late decelerations present w/ preterm labor Ruptured Maternal physical assessment: vitals within normal limits IV: Left wrist, lactated ringers Current meds: Betamethasone, Nifedipine, ampicillin, Magnesium Sulfate Labs: UA for CHS, urinalysis, CBC, CMP, cervical culture Activity: Bedrest R - Recommendation Discharge planning needs: How to care for a preterm child Safe sleep + car seat safety Breast feeding assistance Schedule post partum visit I-SBAR for Direct Patient Care Documentation - Antepartum/Intrapartum PLAN OF CARE: Nursing Analysis/Priority Diagnosis: Deficient of knowledge related to lack of information as evidenced by patient, first child and preterm delivery. Patient Goal: Patient will identify signs and symptoms requiring evaluation & intervention as well as possible outcomes of preterm labor. Outcome Criteria: Client transitions will be able to implement preterm newborn care.