Your text here
Your Name: Savannah Sellars
I D#: D40946977
INTRODUCE
YOURSELF Your Title: Student RN
Reason for being there: Clinical Assessment
S Patient initials: C.C. Age: 28 years old G_1 T_0__P_0__A_0__L_0__
SITUATION Delivery date: 9/18/2019 Time: 2343 Gest. Age: 40 weeks
Sex: male / female Singleton Twin Other
Length of labor: 1st stage: 9 hours 2nd stage: 1.5 hours 3rd stage: 25 minutes
Amniotic fluid rupture: SROM/ AROM Time: 1200 Fluid: Amniotic Fluid
Type of delivery: vaginal - spontaneouas assisted (forceps/ vacuum)
Cesarean – indication type of incision
Episiotomy/ Lacerations: N/A EBL: N/A
APGAR: 1 min: 8 5 min: 10 10 min: 10 Resuscitation measures: N/A
Complications: N/A
B Previous pregnancies – N/A, no previous pregnancies
BACKGROUND Current pregnancy Prenatal care: yes no GBS status: pos neg Breast feeding: yes no
Labs: Accu-checks, Rh factor, GBS, HIV, gonorrhea/chlamydia, syphilis
Complications: Gestational Diabetes Mellitus
Past Medical History: Unremarkable Family Support: Husband (Kyle Fox)
Home Medications: None
A Mother Newborn
ASSESSMENT Temp: 36.9 oral BP: 130/78 HR: 86 RR: 16 Temp: 36.8 ax HR: 144 RR: 36 BP: 64/42
Pain: 4/10 vaginal area Pain: asleep
General: Great mood & affect, excited
Birth weight: 8 lb. 0 oz. / 3,629 g.
Activity: Ambulatory
Cardiovascular: Heart sounds WNL, no murmurs Length: 52cm Head: 35cm Chest: 33cm
Resp: Clear, even, unlabored, no accessory muscle Gest. Age by Ballard: 40 SGA/AGA/LGA
use
General appearance (Activity/tone/cry): Well-
Breast: Soft, pliable, intact & everted b/L
flexed, active movements of arms & legs, good cry
Uterus: Normal size & shape, mobile, regular, firm,
Skin: Pink all over
midline, below the umbilicus & nontender
Bowel: Has passed her bowels Head and neck: Mild caput succedaneum, no other
Bladder: Voided bladder @ 0134 abnormalities; full ROM of neck
Lochia: Light odorless dark red discharge w/o clots Chest/Cardio/Resp: Equal & clear breath sounds &
Perineum: Perineum intact, some discomfort chest expansion, heart sounds WNL
Hemorrhoids: None present Abdomen: Soft, non-tender, no palpable
Extremities: Symmetric, no discoloration, no abnormalities
tenderness Musculoskeletal: Normal ROM on all joints,
RhoGam needed: yes no Ortolani & Barlow maneuver WNL
This study source was downloaded by 100000839739811 from CourseHero.com on 04-02-2022 15:43:39 GMT -05:00
https://www.coursehero.com/file/65468248/Teaching-Prenatal-Newborn-Care-ISBAR-Care-Plandocx/
Your Name: Savannah Sellars
I D#: D40946977
INTRODUCE
YOURSELF Your Title: Student RN
Reason for being there: Clinical Assessment
S Patient initials: C.C. Age: 28 years old G_1 T_0__P_0__A_0__L_0__
SITUATION Delivery date: 9/18/2019 Time: 2343 Gest. Age: 40 weeks
Sex: male / female Singleton Twin Other
Length of labor: 1st stage: 9 hours 2nd stage: 1.5 hours 3rd stage: 25 minutes
Amniotic fluid rupture: SROM/ AROM Time: 1200 Fluid: Amniotic Fluid
Type of delivery: vaginal - spontaneouas assisted (forceps/ vacuum)
Cesarean – indication type of incision
Episiotomy/ Lacerations: N/A EBL: N/A
APGAR: 1 min: 8 5 min: 10 10 min: 10 Resuscitation measures: N/A
Complications: N/A
B Previous pregnancies – N/A, no previous pregnancies
BACKGROUND Current pregnancy Prenatal care: yes no GBS status: pos neg Breast feeding: yes no
Labs: Accu-checks, Rh factor, GBS, HIV, gonorrhea/chlamydia, syphilis
Complications: Gestational Diabetes Mellitus
Past Medical History: Unremarkable Family Support: Husband (Kyle Fox)
Home Medications: None
A Mother Newborn
ASSESSMENT Temp: 36.9 oral BP: 130/78 HR: 86 RR: 16 Temp: 36.8 ax HR: 144 RR: 36 BP: 64/42
Pain: 4/10 vaginal area Pain: asleep
General: Great mood & affect, excited
Birth weight: 8 lb. 0 oz. / 3,629 g.
Activity: Ambulatory
Cardiovascular: Heart sounds WNL, no murmurs Length: 52cm Head: 35cm Chest: 33cm
Resp: Clear, even, unlabored, no accessory muscle Gest. Age by Ballard: 40 SGA/AGA/LGA
use
General appearance (Activity/tone/cry): Well-
Breast: Soft, pliable, intact & everted b/L
flexed, active movements of arms & legs, good cry
Uterus: Normal size & shape, mobile, regular, firm,
Skin: Pink all over
midline, below the umbilicus & nontender
Bowel: Has passed her bowels Head and neck: Mild caput succedaneum, no other
Bladder: Voided bladder @ 0134 abnormalities; full ROM of neck
Lochia: Light odorless dark red discharge w/o clots Chest/Cardio/Resp: Equal & clear breath sounds &
Perineum: Perineum intact, some discomfort chest expansion, heart sounds WNL
Hemorrhoids: None present Abdomen: Soft, non-tender, no palpable
Extremities: Symmetric, no discoloration, no abnormalities
tenderness Musculoskeletal: Normal ROM on all joints,
RhoGam needed: yes no Ortolani & Barlow maneuver WNL
This study source was downloaded by 100000839739811 from CourseHero.com on 04-02-2022 15:43:39 GMT -05:00
https://www.coursehero.com/file/65468248/Teaching-Prenatal-Newborn-Care-ISBAR-Care-Plandocx/
