MATERNITY NR 327 I-SBAR for Direct Patient Care Documentation Antepartum/Intrapartum
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Course
I-SBAR
Institution
I-SBAR
MATERNITY NR 327 I-SBAR for Direct Patient Care Documentation Antepartum/Intrapartum
Your Name:
D#:
Your Title: Student RN
Reason for being there: Real Life scenario
S
SITUATION
Patient initials: T.A. Age: 38 G___1_T__0__P__0__A_0___L__0__
EDC: 4/20 LMP: 7/13 Gest. Age: 11 /7 weeks
Singlet...
maternity nr 327 i sbar for direct patient care documentation antepartumintrapartum
your name d your title student rn reason for being there real life scenario s situation patient initials ta
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I-SBAR for Direct Patient Care Documentation
Antepartum/Intrapartum
Your Name:
I D#:
INTRODUCE
YOURSELF Your Title: Student RN
Reason for being there: Real Life scenario
S Patient initials: T.A. Age: 38 G___1_T__0__P__0__A_0___L__0__
SITUATION EDC: 4/20 LMP: 7/13 Gest. Age: 11 /7 weeks
Singleton Twin Other
Reason for admit: First prenatal visit
Fetal movement: present not present
Membrane status: Intact Ruptured Information NOT given Date Time: Fluid:
B Previous pregnancies
BACKGROUND
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: yes no GBS status: pos neg Breast feeding: yes no
Labs:
Complications: Gestational Diabetes
Past Medical History: Hypotension Family Support: Husband
Home Medications: Prenatal Vitamins
A Vital Signs:
ASSESSMENT TEMP B/P HR RR SP02 PAIN FHTs
98.8 135/90 80 16 N/A 0 N/A
Labor status: onset: stage /phase:
Vaginal exam: _____/______/______ Blood/fluid ____________________
Planned method of delivery: vaginal c/section Undetermined at this time
Fetal heart rate pattern: reassuring non-reassuring
Contraction pattern: frequency duration strength
Labor progress: N/A
Maternal physical assessment: Skin intact, No mass, lesion or infestation of the head and hair, denies
blurred vison, Respiratory is WNL, Breast is tender, heart sound WNL and No edema, Bowel sound
active in all four quadrant, reports occasional nausea, urine is straw color with no alteration of
urination, Genitalia is WNL, Musculoskeletal WNL, Neurological DTR +2. Immunizations up to date
This study source was downloaded by 100000829818949 from CourseHero.com on 04-25-2022 10:48:53 GMT -05:00
ISBAR NR327 Antepartum-Intrapartum_DirectPatientCare_Documentation New: Nov19
https://www.coursehero.com/file/72204586/Real-Life-Scenario-Gestational-Diabetesdocx/
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