Exam (elaborations)
NR 327-Ante/Intrapartum Preterm Labor/GDM ISBAR
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Ante/Intrapartum Preterm Labor/GDM ISBAR
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CHAMBERLAIN COLLEGE OF NURSING NR 327 Ante/Intrapartum Preterm labor/GDM ISBARI Your Name: Tashara Smith Your Title: Student RN
Reason for Being There: Assist with provision of care
Date: 03/26/XX
S Patient initials: MG Age: 27 G: 1 T: 0 P: 0 A: 0 L: 0
Allergies: No Known Allergies
Attending Physician: Dr. Patricia Rogers
EDC/EDD: 08/31/XX LMP: 11/24/XX Gest. Age: 33.6 /7 weeks
Singleton Twin Other
Reason for admit: Patient complains of back pain and a burning sensation when voiding
Fetal movement: present not present
Membrane status: Intact upon arrival Ruptured Date: Time: Fluid color:
B Previous pregnancies
Year Type of delivery Labor Length Complications
N/A N/A N/A N/A
N/A N/A N/A N/A
Current pregnancy
Prenatal care: Not provided GBS status: Not provided Breast feeding: Not provided
Immunizations: Not provided
Labs: Not provided, no labs on file prior to day of admission
Complications: Not provided, no complications listed prior to the date of admission
Past Medical History: Not provided
Social History: Not provided
Family Support: Not provided
Home Medications: Not provided
, Vital Signs
A
DATE TIME TEMP B/P HR RR SP02 PAIN FHTs
03/26/XX 0700 37.0 °C 110/68 80 14 97% 0 128
(98.6°F
)
03/26/XX 0800 37.0 °C 112/72 84 14 96% 0 132
(98.6°F
)
03/26/XX 0900 37.0 °C 110/72 84 14 97% 0 136
(98.6°F
)
03/26/XX 1000 37.0 °C 114/74 86 14 98% 0 134
(98.6°F
)
Labor status: Preterm onset: 1330 while admitted stage /phase: 1st stage in early/latent phase
Vaginal exam assessment: Pt is 2cm dilated Blood/fluid: Small bloody vaginal discharge noted
Fetal heart rate pattern: reassuring non-reassuring- Due to decelerations
Contraction pattern: frequency: Not provided duration: Not Provided strength: Not provided
Labor progress: Complicated due to PROM and prolapse of umbilical cord
Planned method of delivery: vaginal c/section Due to prolapsing of cord &
decelerations of FHR
Maternal physical assessment: Not provided
Diet: NPO (Nothing by mouth) Weight: 59kg (130lb) IV: Lactated Ringer’s solution at 100mL/hr
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