CHAMBERLAIN COLLEGE OF NURSING NR 327 Postpartum ISBAR
Name: Angela Lambert Your Title: Student Nurse
I Reason for Being There: Post-Partum Care
Time:
1800
Date: 10/14/xx
Patient initials: P.H. Age: 28y G1T1P0A0L1
S Delivery date: 10/14/xx time: 0700 Gest. Age: 41 0/7 weeks
Allergies:
Sex: male / female Singleton Twin Other Pollen,
Cats,
Dogs
Length of labor: 1st stage 2nd stage: 3 Hours 3rd stage 15hrs total
Amniotic fluid rupture: SROM/ AROM Date/Time: Fluid color: Attending
Physician:
Type of delivery: vaginal - spontaneous assisted (forceps/ vacuum)
Cesarean (indication): type of incision: Lowentha
lJulie
Episiotomy/ Lacerations: Midline EBL: 250ml
, APGAR: 1min=7 5 min=8 10 min Resuscitation measures:
Complications: Chorioamnionitis
Previouspregnancies
B Year Type of delivery Labor Length Complications
Currentpregnancy Prenatal care: yes no GBS status: pos neg Breast feeding: yes no Blood
type: B (-) Rubella: Immune Hep B: Negative HIV: Negative RPR: Non-Reactive Labs: H&H baseline
12/38% 10/14/xx Hb 10.8 Hct 23% Platelets 135,000/mm3
Complications: Chorioamnionitis, post-partum hemorrhage, Uterine Curettage & Balloon, Blood Trans.
Past Medical History: Asthma Social History: Family Support: Husband
Home Medications: Inhaler
Mother
A Vital Signs:
TIME TEMP B/P HR RR PAIN
1600 38°C 94/66 96 20 1/10
1700 37.3°C 106/72 96 20 1/10
1800 37.2° C 104/70 92 22 1/10
General appearance:
Color appropriate for ethnics, A&O X 4, Fatigue now resolved, eating and drinking reg. Diet
Activity:
Moderate activity, tolerating self-care better than before operation
Cardiovascular:
Heart rate and rhythm even and strong, no murmurs or abnormal heart sounds heard
Resp:
Even and rhythmic post-surgery, Respirations in the 20’s
Breast:
Uterus:
U, Midline, Firm, Intact
Bowel:
No bowels passed since birth
Bladder:
Voided 275ml at 1700
Lochia:
Small, Rubra
Perineum:
Mid line episiotomy
Hemorrhoids:
Name: Angela Lambert Your Title: Student Nurse
I Reason for Being There: Post-Partum Care
Time:
1800
Date: 10/14/xx
Patient initials: P.H. Age: 28y G1T1P0A0L1
S Delivery date: 10/14/xx time: 0700 Gest. Age: 41 0/7 weeks
Allergies:
Sex: male / female Singleton Twin Other Pollen,
Cats,
Dogs
Length of labor: 1st stage 2nd stage: 3 Hours 3rd stage 15hrs total
Amniotic fluid rupture: SROM/ AROM Date/Time: Fluid color: Attending
Physician:
Type of delivery: vaginal - spontaneous assisted (forceps/ vacuum)
Cesarean (indication): type of incision: Lowentha
lJulie
Episiotomy/ Lacerations: Midline EBL: 250ml
, APGAR: 1min=7 5 min=8 10 min Resuscitation measures:
Complications: Chorioamnionitis
Previouspregnancies
B Year Type of delivery Labor Length Complications
Currentpregnancy Prenatal care: yes no GBS status: pos neg Breast feeding: yes no Blood
type: B (-) Rubella: Immune Hep B: Negative HIV: Negative RPR: Non-Reactive Labs: H&H baseline
12/38% 10/14/xx Hb 10.8 Hct 23% Platelets 135,000/mm3
Complications: Chorioamnionitis, post-partum hemorrhage, Uterine Curettage & Balloon, Blood Trans.
Past Medical History: Asthma Social History: Family Support: Husband
Home Medications: Inhaler
Mother
A Vital Signs:
TIME TEMP B/P HR RR PAIN
1600 38°C 94/66 96 20 1/10
1700 37.3°C 106/72 96 20 1/10
1800 37.2° C 104/70 92 22 1/10
General appearance:
Color appropriate for ethnics, A&O X 4, Fatigue now resolved, eating and drinking reg. Diet
Activity:
Moderate activity, tolerating self-care better than before operation
Cardiovascular:
Heart rate and rhythm even and strong, no murmurs or abnormal heart sounds heard
Resp:
Even and rhythmic post-surgery, Respirations in the 20’s
Breast:
Uterus:
U, Midline, Firm, Intact
Bowel:
No bowels passed since birth
Bladder:
Voided 275ml at 1700
Lochia:
Small, Rubra
Perineum:
Mid line episiotomy
Hemorrhoids:
