NR 327 Antepartum/Intrapartum ISBAR

Name

Chamberlain University

NR-327: Maternal-Child Nursing

Prof. Name

Date

NR 327 Antepartum/Intrapartum ISBAR

I. Identification

Name	Your Title	Reason for Being There	Clinical Date	Time
K.K.	Student Nurse	Clinical	05/02/xx	08:88am

S. Situation

Patient Initials	Age	Gravida	Term	Preterm	Abortion	Living	EDC	LMP	Gestational Age	Singleton	Reason for Admit	Fetal Movement	Membrane Status
K.K.	25	G1	T0	P0	A0	L0	N/A	N/A	27 weeks	Singleton	Sudden increase in weight gain, nausea, vomiting, blurred vision, headache	Present	Intact

F. Findings

Date	Time	Fluid Color	Allergies	Attending Physician
05/02/2018	1:30pm	N/A	No known allergies	Dr. Hunt Kelly

B. Background

Previous Pregnancies	Year	Type of Delivery	Labor Length	Complications	Prenatal Care	GBS Status	Breastfeeding
N/A	N/A	N/A	N/A	N/A	Yes	Negative	N/A

Labs	Complications	Past Medical History	Social History	Family Support	Home Medications
Rh antigen, CBC, Urinalysis, CMP, blood type, uric acid	Preeclampsia	N/A	N/A	N/A	Prenatal vitamins

A. Assessment

Time	Temp	B/P	HR	RR	SpO2	Pain	FHTs
1:45pm	36.9°C (98.4°F)	162/98	92/min	22/min	92%	8/10	140
12:00pm	37.0°C	160/100	100	24/min	97%	8/10	120
12:20pm	37.0°C	162/100	94	22/min	97%	8/10	124

Labor Status

Onset	Stage/Phase	Vaginal Exam	Blood/Fluid	Planned Method of Delivery	Fetal Heart Rate Pattern	Contraction Pattern	Frequency	Duration	Strength	Labor Progress
N/A	N/A	__/__/__	N/A	Vaginal	Reassuring	N/A	N/A	N/A	N/A	N/A

R. Recommendations

Maternal Physical Assessment	IV Fluids	Current Medications	Labs	Activity
Urine protein present, Deep tendon reflexes (Achilles) 3+ bilaterally, reported right upper quadrant pain, nausea, vomiting, blurred vision, headaches, visual disturbances, epigastric pain, facial and pedal edema 3+	Lactated Ringers 125ml/hr	Prenatal vitamins, hydralazine 5mg, magnesium sulfate 4g IV bolus, magnesium sulfate 2g/hr, sodium chloride, calcium gluconate 1g IV bolus, hydralazine 5mg IV bolus	Urinalysis, 24-hour urine collection for protein, CBC, MCP, blood type, AST, uric acid, Rh antigen	Bed Rest

Discharge Planning

Notify provider if abdominal pain, nausea, vomiting, abnormal swelling, blurry vision, headache, or decreased urine output occurs.
Strict adherence to new prescriptions, especially hydralazine for high blood pressure.
Follow-up on clinical visits as scheduled.

Plan of Care

Based on the patient’s history, presenting symptoms, lab values, and medications, the patient should be closely monitored for worsening preeclampsia. Fetal monitoring should continue to assess heart rate patterns and movement. The patient should remain on bed rest with IV fluids administered, and blood pressure should be regularly checked. Continue administering prescribed medications and monitor for side effects.

NR 327 Antepartum/Intrapartum ISBAR

References

American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.).