I-SBAR for Direct Patient Care Documentation
Antepartum/Intrapartum
I
INTRODUCE
YOURSELF
Your Name: Lena Saniri
D#40731821
Your Title: Nursing
... [Show More] Student
Reason for being there: Patient Care
Date: 5/17/2020. Time:1330
S
SITUATION
Patient initials: R.R. Age: 25 years old G__1__T__0__P____A__0__L__0__
EDC: n/a LMP: n/a Gest. Age: 27 weeks
Singleton Twin Other
Reason for admit: Sudden weight gain, new onset vomiting, blurred vision, headache
Fetal movement: present not present
Membrane status: n/a Intact n/a Ruptured n/a Date n/a Time: n/a Fluid: n/a
Allergies: NKDA. Attending physician: Kelly Hunt
B
BACKGROUND
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: yes no GBS status: n/a Breast feeding: n/a
Labs: n/a
Complications: Preeclampsia. Past Medical History: n/a Family Support: n/a
Home Medications: Prenatal vitamins
A
ASSESSMENT
Vital Signs:
TEMP B/P HR RR SP02 PAIN FHTs
98.6 162/98 92 22 97% 8/10 n/a
n/a 142/92 92 14 95% 8/10 n/a
Labor status: n/a onset: n/a stage /phase: n/a
Vaginal exam: __05_/_20_/_xx__ Blood/fluid _n/a_
Planned method of delivery: vaginal c/section
Fetal heart rate pattern: reassuring non-reassuring
Contraction pattern: frequency n/a duration n/a strength n/a
Labor progress: n/a
Maternal physical assessment: pedal edema 3+, facial edema, 61kg/160cm, Deep tendon reflex 3+,
sharp UQ pain, no vaginal bleeding, frequent urination
IV: Intact, LR 125mL/hr Current meds: prenatal vitamins, Hydralazine IV bolus, Mg sulfate
Labs: Hgb 12.2. Hct 37%. Activity: Bed rest
R
RECOMMENDATION
Discharge Planning Needs: Preterm newborn care education, car seat safety education, c/section self-care
education.
ISBAR NR327 Antepartum-Intrapartum_DirectPatientCare_Documentation New: Nov19
This study source was downloaded by 100000837860601 from CourseHero.com on 05-14-2022 05:23:29 GMT -05:00
https://www.coursehero.com/file/64012359/wk5-ATI-I-SBAR-Preeclampsia-1docx/
Plan of Care
Nursing Analysis/ Priority Diagnosis: Deficient fluid volume related to fluid shift out of the vascular compartment
AEB Facial edema and pedal edema 3+, elevated blood pressure, and altered kidney fu [Show Less]