MATERNITY NR 327 I-SBAR for Direct Patient Care Documentation Antepartum/Intrapartum

MATERNITY NR 327 I-SBAR for Direct Patient Care Documentation Antepartum/Intrapartum Your Name: D#: Your Title: Student RN Reason for being there: Real Life scenario S SITUATION Patient initials: T.A. Age: 38 G___1_T__0__P__0__A_0___L__0__ EDC: 4/20 LMP: 7/13 Gest. Age: 11 /7 weeks Singleton Twin Other Reason for admit: First prenatal visit Fetal movement: present not present Membrane status: Intact Ruptured Information NOT given Date Time: Fluid: B BACKGROUND Previous pregnancies Year Type of delivery Labor Length Complications N/A N/A N/A N/A N/A N/A N/A N/A Current pregnancy Prenatal care: yes no GBS status: pos neg Breast feeding: yes no Labs: Complications: Gestational Diabetes Past Medical History: Hypotension Family Support: Husband Home Medications: Prenatal Vitamins A ASSESSMENT Vital Signs: TEMP B/P HR RR SP02 PAIN FHTs 98.8 135/90 80 16 N/A 0 N/A Labor status: onset: stage /phase: Vaginal exam: _____/______/______ Blood/fluid ____________________ Planned method of delivery: vaginal c/section Undetermined at this time Fetal heart rate pattern: reassuring non-reassuring Contraction pattern: frequency duration strength Labor progress: N/A Maternal physical assessment: Skin intact, No mass, lesion or infestation of the head and hair, denies blurred vison, Respiratory is WNL, Breast is tender, heart sound WNL and No edema, Bowel sound active in all four quadrant, reports occasional nausea, urine is straw color with no alteration of urination, Genitalia is WNL, Musculoskeletal WNL, Neurological DTR +2. Immunizations up to date ISBAR NR327 Antepartum-Intrapartum_DirectPatientCare_Documentation New: Nov19 This study source was downloaded by from CourseH on :48:53 GMT -05:00 IV: N/A Current meds: Prenatal Vitamins, Regular Insulin Labs: Abnormal Glucose tolerance test, negative protein Activity: Active, states use of walking (1 X weekly) R RECOMMENDATION Discharge Planning Needs: Teach on proper way of to administer insulin, signs and symptoms of hypoglycemia and adherence of dietary modification not to exceed 2,000 calories a day. Have patient perform teach back.. Provide information on smoking cessation for support Plan of Care Nursing Analysis/ Priority Diagnosis: Risk for fetal injury related to elevated maternal glucose levels Patient Goal: Fetus will respond positive to non-stress test and will be born healthy, without any indications of fetal injury Outcome Criteria: Normal stress test and negative OCT and CST Met/ Not met/ partially met: Met Priority Interventions Reasoning Evaluation of intervention 1. Determine client’s diabetic control before conception. Control HbA1c levels, before conception helps reduce the risk of fetal mortality and congenital abnormalities. No personal diagnosis of diabetes, however, Mrs. Anderson stated there is a family history 2. Monitor and keep hypertension under control. Watch for pregnancy induced hypertension (PIH) Hypertension can have an effect on perfusion of the fetus. Diabetes can increase risk of PIH Frequently monitor vital signs and glucose levels 3. Assess fetal movement and fetal heart rate each visit as indicated. Encourage the client to periodically record fetal movements beginning about 18 weeks’ gestation, then daily from 34 weeks’ gestation on. Fetal movement and fetal heart rate may be negatively affected when placental insufficiency and maternal ketosis occur. Fetal heart rate WNL baseline 120-160/min with positive fetal movement. 4. Monitor urine for ketones. Assess fruity breath Maternal ketonemia can lead to CNS damage or fetal death especially in the third trimester. Monitor ketones with urine dipstick and prenatal visits ISBAR NR327 Antepartum-Intrapartum_DirectPatientCare_Documentation New: Nov19 This study source was downloaded by from CourseH on :48:53 GMT -05:00 5. Provide information and reinforce procedure for home blood glucose monitoring and diabetic management Decreased fetal or newborn mortality and morbidity complications and congenital anomalies are associated with glucose control. Frequent monitoring is important and maintenance of blood sugar reduces the incidence of fetal injury