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NR 327 Ante/Intrapartum Preterm Labor/GDM ISBAR
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NR 327 Ante/Intrapartum Preterm Labor/GDM ISBAR
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CHAMBERLAIN COLLEGE OF NURSING NR 327 Antepartum/Intrapartum ISBARTime:
I
6.30am
Patient initials: G.M.H. Age: 27 G 1T0P 0A0L0 Allergies
S EDC: 5/2/2018 LMP: 8/ 5 /2017 Gest. Age: 33 weeks
Singleton: Yes Twin Other No known
Reason for admit: Admit for dysuria and generalized malaise with possible preterm labor allergies
Fetal movement: present not present
Membrane status: Intact Ruptured Date: 3/26 Time: 10.00am
Fluid yellowish color Attending
Physician:
Rogers
Patricia
Previous pregnancies N/A
B Year Type of delivery Labor Length Complications
Current pregnancy Prenatal care: yes no GBS status: pos neg Breast feeding: yes no
Labs: RH-factor, GBS, Urinalysis, Blood Tests, lung maturity test
Complications: underdeveloped lungs, dvt
Past Medical History: N/A Social History: N/A Family Support: N/A
Home Medications: Prenatal vitamins
Vital Signs:
A TIME TEMP B/P HR RR SP02 PAIN FHTs
10:00am 37.0C 114/74 86/min 14/min 98% 6/10 134
Labor status: 2cm onset: 7:30am stage /phase: latent phase
Vaginal exam: 03/15/2018 Blood/fluid: blood discharge
Planned method of delivery: vaginal c/section : Yes
Fetal heart rate pattern: 134 normal reassuring :Yes non-reassuring
Contraction pattern: late deceleration frequency 2-3minutes duration 40-60sec strength:
firm
Labor progress: 5 cm
Maternal physical assessment:
IV: lactated Ringers 150 ml /hr Current meds: Nifedipine, Betemethasone, Ampicillin
Labs: Urinalysis
Activity: Bed Rest
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