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NR 327 Antepartum/Intrapartum Clinical ISBAR Gestational Diabetes
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NR 327 Antepartum/Intrapartum Clinical ISBAR Gestational Diabetes
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CHAMBERLAIN ICOLLEGE IOFINURSING INR I327 IAntepartum/Intrapartum IClinical IISBARName: Your ITitle: IStudent INurse Time:
I IReason I for IBeing IThere: I Clinicals I1 300
Date: I7/22/2018
Patient Iinitials: IA,D Age: I I38 Iy/o G I1 IT I0 IP I0 IAI0 IL I0 Allergies
S EDC: I 4/20/2018 I LMP: I8/13/2017 I Gest. IAge: I11_/7 I weeks IMost ICurrent IGest IAge: INKDA
I38ISingleton Twin Other
Reason Ifor Iadmit: Iinitial Iprenatal Ivisit. IAs Iwell Ias Ivisit Ifor Igestational Idiabetes
I educationIa nd I glucose I testing.
Fetal Imovement: present
Membrane Istatus: Intact SROM AROM No Ipertinent Iinfo Iwas Attending
IgivenIDate: I No I pertinent I info Time: Fluid Icolor: IPhysician:
ID r.
Bockman
Previous Ipregnancies IN/AIPt Iis Icurrently Istill Ipregnant
B Year Type Iof Idelivery Labor ILength Complications
Current Ipregnancy I Prenatal Icare: yes GBS Istatus: Ipos I neg Breast Ifeeding:
I noILabs: IImmunization Iare Iup Ito Idate
Complications: IGestational Idiabetes
Past IMedical IHistory: IHypertension
I
Social IHistory: Ipt Ihas Ia Ihistory Iof Ismoking, Ibut Iis Icurrently Inot Ismoking Ianymore Idue Ito Ipregnancy
Family ISupport: IHusband Iwas Ipresent Iwith Ithe Ipatient Iduring Iprenatal Ivisit
I
Home IMedications: IPrenatal Ivitamins I(during Iinitial Ivisit)
Dates/Results Iof IUltrasounds: INo Iinformation Igiven Iabout Iresults Iof Iultrasounds
Dates I& ITesting IResults: ICST
I
Vital ISigns:
A TIME TEMP B/P HR RR SP02 PAIN FHTs
1330 98.8 IF 135/90 80 16 100% 0/10 156
Labor Istatus: onset: stage I/phase:
Vaginal Iexam: / / Blood/fluid I I
Planned Imethod Iof Idelivery: vaginal c/section
Fetal Iheart Irate Ipattern: I Ireassuring
I
Contraction Ipattern: INo Ipertinent Iinfo Igiven
Labor Iprogress:
I
Maternal Iphysical Iassessment: I@ I2/29 IFundal Iht Iis Iat I20 Icm. I@ I30 Iweeks, IFHR-156, Ipresentation
vtx, Ifetal Imovement Ipresent Iduring Istress Itest, Idenies Ipreterm Ilabor. IBP: I134/82, Iweight-121 Ikg,
, Glucose-trace, Iprotein-negative, IBG-378. IHome Imonitoring: I200-422 Img/dL
IVs: I No IIV Igiven
Current Imeds: Iprenatal Ivitamins, Iregular Iinsulin I(humulin) I25 Iunits I3 Itimes Iper Iday
Labs: I(List Iall ILabs): Iimmunizations Iup Ito Idate: Irubella I(titer) Iimmune, Ivaricella, Itetanus,
pertussis, Ihepatitis IB, Iinfluenza, Ipneumococcal.
I
Activity:infant Iis Ireacting Iduring Istress Itest
Discharge Iplanning Ineeds:
R Dietary Iintake Inot Ito Iexceed I2,000 Icalories Iper Iday. IRegular Iinsulin I(Humulin) I25 Iunits I3 Itimes Iper
Iday.IBi-weekly I non-stress I test I reactive.
Plan Iof ICare
Complete Ithe Ifollowing Iinformation IforIALL I priority Idiagnosis I(list Idx Iin Iorder Iof Ipriority).
Nursing IAnalysis/ IPriority IDiagnosis:
1 Risk Ifor IAltered INutrition: ILess Ithan I body Irequirements
2 Risk Ifor Imaternal IInjury
3 Risk Ifor IFetal IInjury
4 Deficient IKnowledge
Patient IObjectives:
1 Patient Iwill Iknow Ithe Inutritional Ieducation Ifor Imaintaining Iblood Iglucose Iat Ioptimal Ilevel.
2 Patient Iwill Iverbalize Ithe Ifood Ithat Iis Ihealthy Ifor Igestational Idiabetics
3 Patient Iwill Irepeat Iback Ithe Isteps Ito Iusing Ithe Iglucometer Iafter Ipatient Ieducation
Outcome ICriteria: IOutcome ICriteria:
1 Patient Iwill Iverbalize Iunderstanding Iof Iindividual Itreatment Iregimen Iand Ithe Ineed Ifor Ifrequent Iself-monitoring
2 Patient Iwill Ibe Ifree Iof Isigns Iand Isymptoms Iof Idiabetic Iketoacidosis I(fruity Ibreath, Iexcess Ithirst)
3 Patient Iwill Imaintain Ifasting Iserum Iblood Iglucose Ilevels Ibetween I60-100 Img/dL
4
DX Interventions Reasoning/Rationale Evaluation Iof Iintervention
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