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 G1T1P0A0L1
Delivery dat
...
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 G1T1P0A0L1
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
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