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CHAMBERLAIN COLLEGE OF NURSING NR 327 Antepartum/Intrapartum ISBAR
Name: Your Title: Nursing Student Time:
I Reason for Being There: Real Life Scenario; Simulation; Clinical; Unspecifie
Date: 10/19 to 4/25 d
Patient initials: TDA Age: 38 G1P0 Allergies:
S EDC: 04/20 LMP: 07/13 Gest. Age: 11-38 weeks NKDA
Singleton Twin Other
Reason for admit: Prenatal Visits;
Fetal movement: present: @ 15 weeks not present: @ 11 weeks Attending
Membrane status: Intact Ruptured Date: N/A Time: N/A Fluid color: N/A Physician:
Dr.
Michael
Bockman
Year pregnancies
Previous Type of delivery Labor Length Complications
B N/A N/A N/A N/A
Current pregnancy: Prenatal care: yes no GBS status: pos neg Breast feeding: yes (plan to) no
Labs: 10/19 1 hr oral glucose test 121 mg/dL (Negative); 02/15 1 hr oral glucose test 142 mg/dL (Abnormal);
02/16 3 hr oral glucose test 1000 130 mg/dL; 1100 210 mg/dL; 1200 180 mg/dL; 1300 160 mg/dL; 02/29
blood glucose level 378 mg/dL; Home monitoring blood glucose readings range from 200-422 mg/dL
Complications: Gestational Diabetes
Past Medical History: Hypertension Social History: Hx of smoking; quit due to pregnancy; Denies
alcohol use; Denies stress.
Family Support: Husband at bedside
Home Medications: Prenatal Vitamins
Date Weeks TEMP B/P HR RR Weight PAIN FHTs
Gestatio
n
10/19 11 wks 98.8 F 135/90 80/min 16/min 113 kg 0/10 Deferred
(Numeric)
11/16 15 wks 132/88 115 kg 160
12/14 19 wks 139/90 116 kg 150
1/11 23 wks 135/85 117 kg 164
02/15 28 wks 138/87 119 kg 148
02/16 28 wks 136/88 119 kg 152
02/29 30 wks 134/82 121 kg 156
3/14 32 wks 140/90 122 kg 150
03/28 34 wks 144/91 123 kg 160
4/11 36 wks 138/88 124 kg 150
4/25 38 wks 144/92 125 kg 158
This study source was downloaded by 100000838530596 from CourseHero.com on 01-29-2022 03:33:06 GMT -06:00
https://www.coursehero.com/file/32259922/NR-327-AntepartumIntrapartum-ISBAR-1docx/
CHAMBERLAIN COLLEGE OF NURSING NR 327 Antepartum/Intrapartum ISBAR
Name: Your Title: Nursing Student Time:
I Reason for Being There: Real Life Scenario; Simulation; Clinical; Unspecifie
Date: 10/19 to 4/25 d
Patient initials: TDA Age: 38 G1P0 Allergies:
S EDC: 04/20 LMP: 07/13 Gest. Age: 11-38 weeks NKDA
Singleton Twin Other
Reason for admit: Prenatal Visits;
Fetal movement: present: @ 15 weeks not present: @ 11 weeks Attending
Membrane status: Intact Ruptured Date: N/A Time: N/A Fluid color: N/A Physician:
Dr.
Michael
Bockman
Year pregnancies
Previous Type of delivery Labor Length Complications
B N/A N/A N/A N/A
Current pregnancy: Prenatal care: yes no GBS status: pos neg Breast feeding: yes (plan to) no
Labs: 10/19 1 hr oral glucose test 121 mg/dL (Negative); 02/15 1 hr oral glucose test 142 mg/dL (Abnormal);
02/16 3 hr oral glucose test 1000 130 mg/dL; 1100 210 mg/dL; 1200 180 mg/dL; 1300 160 mg/dL; 02/29
blood glucose level 378 mg/dL; Home monitoring blood glucose readings range from 200-422 mg/dL
Complications: Gestational Diabetes
Past Medical History: Hypertension Social History: Hx of smoking; quit due to pregnancy; Denies
alcohol use; Denies stress.
Family Support: Husband at bedside
Home Medications: Prenatal Vitamins
Date Weeks TEMP B/P HR RR Weight PAIN FHTs
Gestatio
n
10/19 11 wks 98.8 F 135/90 80/min 16/min 113 kg 0/10 Deferred
(Numeric)
11/16 15 wks 132/88 115 kg 160
12/14 19 wks 139/90 116 kg 150
1/11 23 wks 135/85 117 kg 164
02/15 28 wks 138/87 119 kg 148
02/16 28 wks 136/88 119 kg 152
02/29 30 wks 134/82 121 kg 156
3/14 32 wks 140/90 122 kg 150
03/28 34 wks 144/91 123 kg 160
4/11 36 wks 138/88 124 kg 150
4/25 38 wks 144/92 125 kg 158
This study source was downloaded by 100000838530596 from CourseHero.com on 01-29-2022 03:33:06 GMT -06:00
https://www.coursehero.com/file/32259922/NR-327-AntepartumIntrapartum-ISBAR-1docx/
