CHAMBERLAIN COLLEGE OF NURSING NR 327 Postpartum ISBAR
Name: Sabrina Birch Your Title: Student Nurse Time:
I Reason for Being There: ATI Scenario 5:35
Date: _3/22/18
Patient initials: PH Age: 28 G_1 T 1 P_1 A 0 L 1 Allergies
S Delivery date: 10/14 time: 0530 Gest. Age: 41 /7
Pollen
weeks Cats
dogs
Sex: male, Singleton
Length of labor: 1st stage 2nd stage 3 hr 3rd stage 15 total hours
Amniotic fluid rupture: SROM/ AROM Date/Time: Fluid color: Attending
Type of delivery: vaginal - spontaneous assisted (forceps/ vacuum) Physician:
Cesarean (indication): type of incision: Dr.
Lowentha
Episiotomy/ Lacerations: midline EBL:250 ml l
APGAR: 1min 7 5 min 8 10 min Resuscitation measures:
Complications: Chorioamnionitis
Year pregnancies
Previous Type of delivery Labor Length Complications
B
Current pregnancy Prenatal care: yes no GBS status: pos neg Breast feeding: yes no
Blood type: B- Rubella:_Immune Hep B: neg HIV: neg RPR: _non
reactive
Labs: Hgb 12, Hct 37%, WBC 8,200, RBC 4.1 million
Complications: Post Partum Hemorrhage, Chorioamnionitis
Past Medical History: Asthma Social History: Family Support:
Home Medications: Inhaler
TIME TEMP B/P HR RR SP02 PAIN
0700 101.7 F 132/72 96 12 95 2/10
0715 100.4 128/70 100 16 96 2/10
0730 100.4 112/70 104 18 98 2/10
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, 2
Mother
A Vital Signs:
General appearance:
Activity:
Cardiovascular:
Resp:
This study source was downloaded by 100000838530596 from CourseHero.com on 01-29-2022 03:22:09 GMT -06:00
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