NR327_ISBAR for Direct Patient Care Documentation_Teaching PrenatalandNewborn
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NR327_ISBAR_TeachingPrenatalandNewborn
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NR327_ISBAR_TeachingPrenatalandNewborn
NR327_ISBAR for Direct Patient Care Documentation_Teaching PrenatalandNewborn
I-SBAR for Direct Patient Care Documentation
Teaching Prenatal and Newborn Care
I
INTRODUCE
YOURSELF
Your Name: Jazzmine Carter Your Title: Student Nurse____
Reason for Being There: __Education; Clinical; Real Lif...
nr327isbar for direct patient care documentationteaching prenatalandnewborn
i sbar for direct patient care documentation teaching prenatal and newborn care i introduce yourself your name jazzmine c
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I-SBAR for Direct Patient Care Documentation
Teaching Prenatal and Newborn Care
Your Name: Jazzmine Carter Your Title: Student Nurse____ Time:
I 0930
INTRODUCE
YOURSELF
Reason for Being There: __Education; Clinical; Real Life Scenario__________
Date: September 2, 2020
Patient initials: CC Age: 28 G 1 T 0 P_0_A_0_L_0__ Allergies:
S NKA
SITUATION
Diet: Height: Weight:
Obstetrician:
EDD: 9/24/2020 LMP: Trimester: Third Trimester Dr. George Trimble
X Singleton □ Twin □ Other Pediatrician:
Dr. Aanya Patel
Reason for visit: _________
Fetal movement: □ present □ not present
Previous pregnancies
B
BACKGROUND Year Type of delivery Labor Length Complications
N/A N/A N/A N/A
Current pregnancy
Prenatal care: X yes □ no Breast feeding: X yes □ no
Past Medical History: _________N/A____ Social History:_____N/A_______
Family Support: Husband________
A Newborn: Initials: N/A____
ASSESSMENT
XBoy □Girl Delivery method: _______N/A__ Birthdate: ___N/A___ Time: ____N/A__
This study source was downloaded by 100000829818949 from CourseHero.com on 04-25-2022 13:09:23 GMT -05:00
NR327 ISBAR Teaching Prenatal and Newborn Care Documentation New: May20
https://www.coursehero.com/file/70236209/NR327-ISBAR-TeachingPrenatalandNewborn-9-4-1docx/
, Newborn Input & Output:
DATE Time Breastfeedin LATCH Score Formula Urine Stool
g (min) (mL)
N/A N/A N/A N/A N/A N/A N/A
Teaching Topics: What teaching should be included in the topics below? Be Specific and Concise
Birth Plan A birth plan includes things like pain management, birthing options, and newborn feeding prefere
plan is the primary tool for communicating with nurses about the family’s goals and priorities, an
of support from caregivers would be most helpful to them. It should never be more than one pag
long (in a easily readable format.) One format is to have three sections. The first describes who th
family and who will be at the birth and what they have done to prepare for this birth. The second
gives the big picture of their preferences for labor support, pain medication, and interventions. Th
third is optional, and explains any special information that “if the nurse only knew this about me,
they could better support me.” This is a good place to address religious or cultural preferences,
history of sexual abuse or other personal history that may affect them during the birth process,
any particular worries they have about the birth.
Pain Management CC does not want an epidural however she is interested in the IV medications. CC
can receive meperidine up until 4 hours prior to birth. Opioid analgesics cross
the placenta and can cause respiratory depression in the newborn. Opioid
analgesics should not be given 1 to 4 hours of birth.
Umbilical Cord Care The parents should cleanse the skin at the base of the cord with plain water if
Soiled. The parents should then dry the site thoroughly. The clamp is removed before the baby
goes home from the hospital. The cord stump should fall off in seven to 14 days. When it falls off,
a small amount of blood or wetness is normal. At home, you should: Keep the cord clean and dry.
the cord, the sooner it will fall off. Use a cotton swab dipped in alcohol to clean around the base o
three times a day or when soiled with urine or stool. You may continue to apply alcohol even
after the stump falls off until the area is dry. Do not give your baby a tub bath until the cord falls o
This study source was downloaded by 100000829818949 from CourseHero.com on 04-25-2022 13:09:23 GMT -05:00
NR327 ISBAR Teaching Prenatal and Newborn Care Documentation New: May20
https://www.coursehero.com/file/70236209/NR327-ISBAR-TeachingPrenatalandNewborn-9-4-1docx/
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