NR 327 Ante/Intrapartum Preterm labor/GDM ISBAR
I
Your Name: Tashara Smith Your Title: Student RN
Reason for Being There: Assist with provision of
... [Show More] 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
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A
Vital Signs
DATE TIME TEMP B/P HR RR SP02 PAIN FHTs
03/26/XX 0700 37.0 °C
(98.6°F
)
110/68 80 14 97% 0 128
03/26/XX 0800 37.0 °C
(98.6°F
)
112/72 84 14 96% 0 132
03/26/XX 0900 37.0 °C
(98.6°F
)
110/72 84 14 97% 0 136
03/26/XX 1000 37.0 °C
(98.6°F
)
114/74 86 14 98% 0 134
Labor status: Preterm onset: 1330 while admitted stage /phase: 1
st 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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Current meds: Betamethasone (Celestone) 12mg IM once, Ampicillin (Ampicin) 1 gram IV every
4hr, Nifedipine (Procardia) 10 mg PO every 4 hr PRN, Lactated Ringer’s solution IV at 100mL/hr, and
Magnesium sulfate solution IV at 2mh/hr
Labs: Urinalysis
Appearance: Cloudy
Color: Dark yellow
Odor: Slight
Specific Gravity: 1.030
PH: 6.2
Protein: 3mg/dL
Leukocyte esterase: Positive
Nitrites: Negative
Ketones: Negative
Glucose: Positive
WBC: >200
RBC: < 3
Bacteria: Positive
Activity: Bed rest with Foley catheter in place
R
Discharge planning needs: Patient should use pain medication as prescribed. Avoid heavy lifting, climbing of
stairs, and driving per MD orders. Return to the hospital if you experience a fever, excessive swelling and
bleeding at the incision site, fouls smell, or purulent drainage at the incision site. Referrals for transportation
and food pantries provided.
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Plan of Care
(Include assessment/interventions not included in scenario based on the patient’s history, presenting symptoms,
lab values, and medications)
Complete the following information for all priority diagnosis (list dx in order of priority).
Nursing Analysis/ Priority Diagnosis: Ineffective tissue perfusion to fetus r/t uterine contractions as evidenced by
late decelerations of the fetal heart rate.
Risk for injury to the fetus r/t inadequate supply of oxygen.
Patient Goal: Delay preterm labor with the absence of fetal distress.
Outcome Criteria: FHR will become stable without injury to the unborn child
Met/ Not met/ partially met: Met, labor was delayed for 2 days in the absence of fetal distress and injury
Priority Interventions Reasoning/Rationale Evaluation of intervention
1. Change maternal position The change in maternal position
will enable blood circulation to the
unborn child and assist with
oxygenation.
Maternal position was changed
and FHR stabilized
2. Increase the lactated ringer (IV)
fluids.
To increase maternal blood
volume. More blood volume
means a less risk for hypotension
and prevents fetal distress
Intervention is effective, VS (B/P,
HR) are within normal parameters.
Pt denies feeling dizzy.
3. Assess and record the
frequency, duration & strength of
contractions and relay them to the
provider.
Provider may order Indomethacin
to suppress uterine contractions
instead of magnesium sulfate. This
may be successful with delaying
labor giving Betamethasone time
to work since two injections 24 hrs
apart are required for
effectiveness. Assuming there
wasn’t a prolapse of the cord
Uterine contractions decreased
while pt stayed admitted for the
next 2 days. The 2nd dose of
Betamethasone was 24hrs later.
Child was born 34.1 weeks of
gestation via cesarean section
4. Administer oxygen per
physician orders
This will increase oxygenation to
the unborn child, reducing the risk
of injury. Pt preterm labor may be
caused by uteroplacental
insufficiency
Late decelerations of FHR are no
longer existing
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5. Stay with the patient and
monitor fetal well being
continuously
This would help in reducing
anxiety, which could cause
maternal stress leading to fetal
distress
Px is focused on relaxation and
states “thank you for staying with
me and helping me feel better [Show Less]