NR 327 Postpartum ISBAR,CHAMBERLAIN COLLEGE OF NURSING NR 327 Postpartum ISBAR,Plan of Care (Include interventions no included in scenario based on the patient’s history, presenting symptoms, values, and medications)
Complete the following information for all priority diagnosis (list dx in ord...
CHAMBERLAIN COLLEGE OF NURSING NR 327 Postpartum ISBAR I Name: Angela Lambert Your Title: Student Nurse Reason for Being There: Post-Partum Care Date: 10/14/xx Time: 1800 S Patient initials: P.H. Age: 28y G1T1P0A0L1 Delivery date: 10/14/xx time: 0700 Gest. Age: 41 0/7 weeks Sex: male / female Singleton Twin Other Length of labor: 1st stage 2nd stage: 3 Hours 3rd stage 15hrs total Amniotic fluid rupture: SROM/ AROM Date/Time: Fluid color: Type of delivery: vaginal - spontaneous assisted (forceps/ vacuum ) Cesarean (indication): type of incision: Episiotomy/ Lacerations: Midline EBL: 250m l APGAR: 1min=7 5 min=8 10 min Resuscitation measures: Complications: Chorioamnionitis Allergies: Pollen, Cats, Dogs Attending Physician: Lowentha lJulie B Previous pregnancies Current pregnancy Prenatal care: yes no GBS status: pos neg Breast feeding: yes no Blood type: B (-) Rubella: Immune Hep B: Negative HIV: Negative RPR: Non-Reactive Labs: H&H baseline 12/38% 10/14/xx Hb 10.8 Hct 23% Platelets 135,000/mm3 Complications: Chorioamnionitis, post-partum hemorrhage, Uterine Curettage & Balloon, Blood Trans. Past Medical History : Asthma Social History: Family Support: Husband Home Medications : Inhaler A Mother Vital Signs: General appearance: Color appropriate for ethnics, A&O X 4, Fatigue now resolved, eating and drinking reg. Diet Activity: Moderate activity, tolerating self-care better than before operation Cardiovascular: Heart rate and rhythm even and strong, no murmurs or abnormal heart sounds heard Resp: Even and rhythmic post-surgery, Respirations in the 20’s Breast: Year Type of delivery Labor Length Complications TIME TEMP B/P HR RR PAIN 1600 38°C 94/66 96 20 1/10 1700 37.3°C 106/72 96 20 1/10 1800 37.2° C 104/70 92 22 1/10
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