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ISBAR Gestational Diabetes

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CHAMBERLAIN COLLEGE OF NURSING NR 327 Antepartum/Intrapartum Clinical ISBAR I Name: Your Title: Student Nurse Reason for Being There: Clinicals Date: 7/22/2018 Time: 1300 S Patient initials: A... ,D Age: 38 y/o G 1 T 0 P 0 A 0 L 0 EDC: 4/20/2018 LMP: 8/13/2017 Gest. Age: 11_/7 weeks Most Current Gest Age: 38 Singleton Twin Other Reason for admit: initial prenatal visit. As well as visit for gestational diabetes education and glucose testing. Fetal movement: present Membrane status: Intact SROM AROM No pertinent info was given Date: No pertinent info Time: Fluid color: Allergies NKDA Attending Physician: Dr. Bockman B Previous pregnancies N/A Pt is currently still pregnant Year Type of delivery Labor Length Complications Current pregnancy Prenatal care: yes GBS status: pos neg Breast feeding: no Labs: Immunization are up to date Complications: Gestational diabetes Past Medical History: Hypertension Social History: pt has a history of smoking, but is currently not smoking anymore due to pregnancy Family Support: Husband was present with the patient during prenatal visit Home Medications: Prenatal vitamins (during initial visit) Dates/Results of Ultrasounds: No information given about results of ultrasounds Dates & Testing Results: CST A Vital Signs: TIME TEMP B/P HR RR SP02 PAIN FHTs 1330 98.8 F 135/90 80 16 100% 0/10 156 Labor status: onset: stage /phase: Vaginal exam: _____/______/______ Blood/fluid ____________________ Planned method of delivery: vaginal c/section Fetal heart rate pattern: reassuring Contraction pattern: No pertinent info given Labor progress: Maternal physical assessment: @ 2/29 Fundal ht is at 20 cm. @ 30 weeks, FHR-156, presentation vtx, fetal movement present during stress test, denies preterm labor. BP: 134/82, weight-121 kg, [Show More]

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