CHAMBERLAIN COLLEGE OF NURSING NR 327 Antepartum/Intrapartum Clinical ISBAR
I
Name: Your Title: Student Nurse
Reason for Being There: Clinicals
Date: 7/22/2018
Time:
1300
S
Patient initials: A,D Age: 38 y/o G 1 T
...
CHAMBERLAIN COLLEGE OF NURSING NR 327 Antepartum/Intrapartum Clinical ISBAR
I
Name: Your Title: Student Nurse
Reason for Being There: Clinicals
Date: 7/22/2018
Time:
1300
S
Patient initials: A,D Age: 38 y/o G 1 T 0 P 0 A 0 L 0
EDC: 4/20/2018 LMP: 8/13/2017 Gest. Age: 11_/7 weeks Most Current Gest Age: 38
Singleton Twin Other
Reason for admit: initial prenatal visit. As well as visit for gestational diabetes education
and glucose testing.
Fetal movement: present
Membrane status: Intact SROM AROM No pertinent info was given
Date: No pertinent info Time: Fluid color:
Allergies
NKDA
Attending
Physician:
Dr.
Bockman
B
Previous pregnancies N/A Pt is currently still pregnant
Year Type of delivery Labor Length Complications
Current pregnancy Prenatal care: yes GBS status: pos neg Breast feeding: no
Labs: Immunization are up to date
Complications: Gestational diabetes
Past Medical History: Hypertension
Social History: pt has a history of smoking, but is currently not smoking anymore due to pregnancy
Family Support: Husband was present with the patient during prenatal visit
Home Medications: Prenatal vitamins (during initial visit)
Dates/Results of Ultrasounds: No information given about results of ultrasounds
Dates & Testing Results: CST
A
Vital Signs:
TIME TEMP B/P HR RR SP02 PAIN FHTs
1330 98.8 F 135/90 80 16 100% 0/10 156
Labor status: onset: stage /phase:
Vaginal exam: _____/______/______ Blood/fluid ____________________
Planned method of delivery: vaginal c/section
Fetal heart rate pattern: reassuring
Contraction pattern: No pertinent info given
Labor progress:
Maternal physical assessment: @ 2/29 Fundal ht is at 20 cm. @ 30 weeks, FHR-156, presentation
vtx, fetal movement present during stress test, denies preterm labor. BP: 134/82, weight-121 kg,
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