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NR_327_POSTPARTUM_ISBAR_p.h..docx

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CHAMBERLAIN COLLEGE OF NURSING NR 327 Postpartum ISBAR I Name: Your Title: Student Nurse Reason for Being There: Post-Partum Care Date: 10/14/xx Time: 1800 S Patient initials: P.H. Age: 28y G1T1... P0A0L1 Delivery date: 10/14/xx time: 0700 Gest. Age: 41 0/7 weeks Sex: male / female Singleton Twin Other Length of labor: 1st stage________ 2nd stage: 3 Hours 3rd stage_________ 15hrs total Amniotic fluid rupture: SROM/ AROM Date/Time: Fluid color: Type of delivery: vaginal - spontaneous assisted (forceps/ vacuum) Cesarean (indication):________________ type of incision:__________ Episiotomy/ Lacerations: Midline EBL: 250ml APGAR: 1min=7 5 min=8 10 min Resuscitation measures: Complications: Chorioamnionitis Allergies: Pollen, Cats, Dogs Attending Physician: LowenthalJuli e B Previous pregnancies Year Type of delivery Labor Length Complications Current pregnancy Prenatal care: yes no GBS status: pos neg Breast feeding: yes no Blood type: B (-) Rubella: Immune Hep B: Negative HIV: Negative RPR: Non-Reactive Labs: H&H baseline 12/38% 10/14/xx Hb 10.8 Hct 23% Platelets 135,000/mm3 Complications: Chorioamnionitis, post-partum hemorrhage, Uterine Curettage & Balloon, Blood Trans. Past Medical History: Asthma Social History: Family Support: Husband Home Medications: Inhaler A Mother Vital Signs: TIME TEMP B/P HR RR PAIN 1600 38°C 94/66 96 20 1/10 1700 37.3°C 106/72 96 20 1/10 1800 37.2° C 104/70 92 22 1/10 General appearance: Color appropriate for ethnics, A&O X 4, Fatigue now resolved, eating and drinking reg. Diet Activity: Moderate activity, tolerating self-care better than before operation Cardiovascular: Heart rate and rhythm even and strong, no murmurs or abnormal heart sounds heard Resp: Even and rhythmic post-surgery, Respirations in the 20’s [Show More]

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