NR 327 Antepartum/Intrapartum ISBAR

Student Name

Chamberlain University

NR-327: Maternal-Child Nursing

Prof. Name

Date

NR 327 Antepartum/Intrapartum ISBAR

I. Identification

The following information outlines the patient identification details for the ISBAR report.

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

S. Situation

The situation section summarizes the patient’s obstetric status and reason for admission.

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	Rapid weight gain, nausea, vomiting, blurred vision, headache	Present	Intact

The patient presented with multiple warning signs of possible preeclampsia, including headaches, blurred vision, nausea, vomiting, and sudden weight gain.

F. Findings

This section records clinical findings and physician information.

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

B. Background

Obstetric and Medical Background

The patient has no prior pregnancy history and is receiving prenatal care.

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

Laboratory, Medical, and Social History

Labs Ordered	Complications	Past Medical History	Social History	Family Support	Home Medications
Rh antigen, CBC, Urinalysis, CMP, blood type, uric acid	Preeclampsia	None reported	Not documented	Not documented	Prenatal vitamins

A. Assessment

The assessment includes vital signs and pain status recorded at different times.

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

Labor Status

Onset	Stage/Phase	Vaginal Exam	Blood/Fluid	Planned Delivery	FHR Pattern	Contraction Pattern	Frequency	Duration	Strength	Progress
N/A	N/A	//__	N/A	Vaginal	Reassuring	N/A	N/A	N/A	N/A	N/A

The patient’s elevated blood pressure, persistent pain, and symptoms indicate severe preeclampsia risk, requiring close observation and intervention.

R. Recommendations

Maternal Physical Assessment

Urinalysis indicated proteinuria.
Deep tendon reflexes (Achilles) were 3+ bilaterally.
The patient reported right upper quadrant and epigastric pain.
Symptoms also included nausea, vomiting, blurred vision, headaches, visual disturbances, and severe edema (facial and pedal edema rated 3+).

Treatments and Interventions

IV Fluids	Current Medications	Labs	Activity
Lactated Ringers at 125 ml/hr	Prenatal vitamins, hydralazine 5 mg, magnesium sulfate 4 g IV bolus followed by 2 g/hr infusion, sodium chloride, calcium gluconate 1 g IV bolus, additional hydralazine 5 mg IV bolus	Urinalysis, 24-hour urine protein collection, CBC, CMP, blood type, AST, uric acid, Rh antigen	Bed Rest

Discharge Planning

Upon discharge, the following education and precautions should be emphasized:

Report immediately if abdominal pain, nausea, vomiting, headaches, vision changes, swelling, or decreased urine output occur.
Adhere strictly to prescribed medications, especially hydralazine for hypertension management.
Attend all scheduled prenatal follow-ups to monitor maternal and fetal well-being.

Plan of Care

Based on clinical findings, the patient should be:

Monitored continuously for preeclampsia progression.
Maintained on bed rest with IV fluids to stabilize blood pressure and prevent complications.
Monitored through ongoing fetal surveillance, including heart rate monitoring and movement tracking.
Administered all prescribed medications while observing for potential side effects.
Provided with family education to ensure proper support and compliance with treatment.

This comprehensive plan aims to reduce maternal risks, prevent seizure activity, and ensure optimal fetal outcomes.

References

American College of Obstetricians and Gynecologists. (2020). Gestational hypertension and preeclampsia: ACOG practice bulletin, number 222. Obstetrics & Gynecology, 135(6), e237-e260. https://doi.org/10.1097/AOG.0000000000003891

NR 327 Antepartum/Intrapartum ISBAR

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