Ante/Intrapartum Preterm labor/GDM ISBAR- NR 327

I 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 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 A Vital Signs 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 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