NR 327 RLS Preterm Labor ISBAR.
CHAMBERLAIN COLLEGE OF NURSING NR 327 Antepartum/Intrapartum ISBAR
I Name: Your Title: Student Nurse
Reason for Being There: Real life scenario; Simulation; Clinical;
Time:
0700 to
1700
Date: 03/24-03/26 for scenario/simulation. Class Date: 07/26/2018
S Patient initials: MG Age: 27 G1P0 Allergies:
NKDA
EDC: Unspecified LMP: Unspecified Gest. Age: 33 weeks
Singleton Twin Other
Reason for admit: Dysuria and generalized malaise with possible preterm labor
Fetal movement: present not present Attending
Physician:
Membrane status: Intact Ruptured towards end of scenario with no description on
Patricia
time, color, or amount. Rogers
B Previous
Year pregnancies
N/A
Type of delivery Labor Length Complications
Current pregnancy Prenatal care: ? Unspecified GBS status: ? Unspecified Breast feeding: Unspecified
Labs: No previous labs to compare; UA results documented in assessment.
Complications: Unspecified
Past Medical History: Unspecified Social History: Unspecified Family Support: No one at
bedside; Unspecified
Home Medications: Unspecified
A Vital Signs: 03/24
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, NR 327 RLS Preterm Labor ISBAR.
Vitals 03/26
Labor status: Preterm/Early Stage /phase: First/Latent
Vaginal exam: 03/24 & 03/26 Blood/fluid: Bloody vaginal discharge
Planned method of delivery: vaginal c/section
Fetal heart rate pattern: reassuring non-reassuring
Contraction pattern: Unspecified frequency: Unspecified duration: Unspecified
strength: Unspecified
Labor progress: @0810: 2 cm dilated and 25 % effacement; Delivery of fetus towards end of
scenario but unspecified.
Maternal physical assessment: 27-year-old African American female at 33 weeks’ gestation who
appears to have adequate nourishment. Mood and affect appropriate to situation. Skin is appropriate
for ethnicity. Vitals WNL. She has right lower back pain with abdominal pain, tightness, and mild
cramping. Urinary discomfort with burning. Vaginal exam results showed bloody discharge with 2
cm dilation and 25% effacement.
IV: Lactated Ringer’s solution at 100 mL/hr; Magnesium Sulfate IV at 2 mg/hr
Current meds: Betamethasone 12 mg IM once, Ampicillin 1 gram IV every 4 hr given at 1200,
Nifedipine 10 mg PO every 4 hr PRN for labor given at 0830 & 1330.
This study source was downloaded by 100000832558064 from CourseHero.com on 01-23-2022 11:04:25 GMT -06:00
https://www.coursehero.com/file/41863489/RLS-Preterm-Labor-ISBARdocx/
CHAMBERLAIN COLLEGE OF NURSING NR 327 Antepartum/Intrapartum ISBAR
I Name: Your Title: Student Nurse
Reason for Being There: Real life scenario; Simulation; Clinical;
Time:
0700 to
1700
Date: 03/24-03/26 for scenario/simulation. Class Date: 07/26/2018
S Patient initials: MG Age: 27 G1P0 Allergies:
NKDA
EDC: Unspecified LMP: Unspecified Gest. Age: 33 weeks
Singleton Twin Other
Reason for admit: Dysuria and generalized malaise with possible preterm labor
Fetal movement: present not present Attending
Physician:
Membrane status: Intact Ruptured towards end of scenario with no description on
Patricia
time, color, or amount. Rogers
B Previous
Year pregnancies
N/A
Type of delivery Labor Length Complications
Current pregnancy Prenatal care: ? Unspecified GBS status: ? Unspecified Breast feeding: Unspecified
Labs: No previous labs to compare; UA results documented in assessment.
Complications: Unspecified
Past Medical History: Unspecified Social History: Unspecified Family Support: No one at
bedside; Unspecified
Home Medications: Unspecified
A Vital Signs: 03/24
This study source was downloaded by 100000832558064 from CourseHero.com on 01-23-2022 11:04:25 GMT -06:00
https://www.coursehero.com/file/41863489/RLS-Preterm-Labor-ISBARdocx/
, NR 327 RLS Preterm Labor ISBAR.
Vitals 03/26
Labor status: Preterm/Early Stage /phase: First/Latent
Vaginal exam: 03/24 & 03/26 Blood/fluid: Bloody vaginal discharge
Planned method of delivery: vaginal c/section
Fetal heart rate pattern: reassuring non-reassuring
Contraction pattern: Unspecified frequency: Unspecified duration: Unspecified
strength: Unspecified
Labor progress: @0810: 2 cm dilated and 25 % effacement; Delivery of fetus towards end of
scenario but unspecified.
Maternal physical assessment: 27-year-old African American female at 33 weeks’ gestation who
appears to have adequate nourishment. Mood and affect appropriate to situation. Skin is appropriate
for ethnicity. Vitals WNL. She has right lower back pain with abdominal pain, tightness, and mild
cramping. Urinary discomfort with burning. Vaginal exam results showed bloody discharge with 2
cm dilation and 25% effacement.
IV: Lactated Ringer’s solution at 100 mL/hr; Magnesium Sulfate IV at 2 mg/hr
Current meds: Betamethasone 12 mg IM once, Ampicillin 1 gram IV every 4 hr given at 1200,
Nifedipine 10 mg PO every 4 hr PRN for labor given at 0830 & 1330.
This study source was downloaded by 100000832558064 from CourseHero.com on 01-23-2022 11:04:25 GMT -06:00
https://www.coursehero.com/file/41863489/RLS-Preterm-Labor-ISBARdocx/
