ISBAR Post Partum Newborn

profileJaida515
Home>Homework Answsers>Nursing homework help
time


  • 3 years ago
  • 10
Report issue
files (1)

PostPartumNewbornISBAR08122023.pdf

I-SBAR FOR DIRECT PATIENT CARE DOCUMENTATION POST-PARTUM/NEWBORN

I Introduce yourself

Your Name: Your Title: Reason for being there:

D#:

S Situation

Patient Initials:

Delivery Date:

Sex: Male / Female

Length of labor:

Amniotic fluid rupture: ❑ SROM ❑ AROM

Type of delivery: ❑ Vaccum ❑ Forceps

Episiotomy/Lacerations:

APGAR: 1min 5 min 10 min

Complications:

Age: G____T____P____A____L____

Time: Gest. Age: /7 weeks

Singleton Twin Other

1st stage________ 2nd stage________ 3rd stage_________

Time: Fluid:

Cesarean – indication Type of incision

EBL:

Resuscitation measures:

B Background

Previous Pregnancies:

Current Pregnancy Prenatal Care: ❑ Yes ❑ No GBS Status: pos neg Breast Feeding: ❑ Yes ❑ No Labs: Complications: Past Medical History: Family Support: Home Medications:

A Assessment

MOTHER NEWBORN

Temp: BP: HR: RR: Pain: Temp: BP: HR: RR: Pain:

General: Birth weight: LB: OZ: / grams

Activity: Length: Head: Chest:

Cardiovascular: Gest. Age by Ballard: SGA/AGA/LGA

Resp: General appearance: (Activity/tone/cry)

Breast:

Uterus: Skin:

Bowel: Head and neck:

Bladder: Chest/Cardio/Resp:

Lochia:

Perineum: Abdomen:

Hemorrhoids: Musculoskeletal:

COLLEGE of NURSING

National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu

Please visit chamberlain.edu/locations for location specific address, phone and fax information.

12-200083 ©2020 Chamberlain University LLC. All rights reserved. 0420culcpe

YEAR TYPE OF DELIVERY LABOR LENGTH COMPLICATIONS

I-SBAR FOR DIRECT PATIENT CARE DOCUMENTATION POST-PARTUM/NEWBORN

A Assessment

MOTHER NEWBORN

Extremities: Genitourinary:

RhoGam needed: ❑ YES ❑ NO Reflexes present: Chest:

IV: MEDS: Gest. Age by Ballard: SGA/AGA/LGA

Labs: Output: Void Stool

Psycho social adaptation/ Rubin’s Phase:

Labs:

R Recommendation

Discharge Planning Needs:

Plan of Care: Nursing Analysis/ Priority Diagnosis:

Patient Goal:

Outcome Criteria:

Met/ Not met/ Partially met

PRIORITY INTERVENTIONS REASONING EVALUATION OF INTERVENTION

1.

2.

3.

4.

5.

COLLEGE of NURSING

National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu

Please visit chamberlain.edu/locations for location specific address, phone and fax information.

NR327_ ISBAR PP-NB_DirectPatientCare Documentation_V1 New: Nov19

  1. Text Field 2:
  2. Text Field 173:
  3. Text Field 177:
  4. Text Field 183:
  5. Text Field 185:
  6. Text Field 192:
  7. Text Field 193:
  8. Text Field 194:
  9. Text Field 195:
  10. Text Field 196:
  11. Text Field 199:
  12. Text Field 200:
  13. Text Field 2011:
  14. Text Field 2016:
  15. Text Field 2012:
  16. Text Field 2014:
  17. Text Field 2015:
  18. Text Field 2013:
  19. Text Field 204:
  20. Text Field 201:
  21. Text Field 205:
  22. Text Field 202:
  23. Text Field 206:
  24. Text Field 203:
  25. Text Field 207:
  26. Text Field 197:
  27. Text Field 198:
  28. Text Field 188:
  29. Text Field 189:
  30. Text Field 190:
  31. Text Field 186:
  32. Text Field 187:
  33. Text Field 184:
  34. Text Field 178:
  35. Text Field 208:
  36. Text Field 209:
  37. Text Field 2010:
  38. Text Field 179:
  39. Text Field 180:
  40. Text Field 181:
  41. Text Field 182:
  42. Text Field 174:
  43. Text Field 175:
  44. Text Field 176:
  45. Text Field 66:
  46. Text Field 52:
  47. Text Field 53:
  48. Text Field 37:
  49. Text Field 78:
  50. Text Field 67:
  51. Text Field 79:
  52. Text Field 83:
  53. Text Field 84:
  54. Text Field 85:
  55. Text Field 86:
  56. Text Field 87:
  57. Text Field 88:
  58. Text Field 89:
  59. Text Field 91:
  60. Text Field 94:
  61. Text Field 95:
  62. Text Field 98:
  63. Text Field 169:
  64. Text Field 167:
  65. Text Field 170:
  66. Text Field 96:
  67. Text Field 92:
  68. Text Field 93:
  69. Text Field 90:
  70. Text Field 38:
  71. Text Field 71:
  72. Text Field 72:
  73. Text Field 77:
  74. Text Field 73:
  75. Text Field 74:
  76. Text Field 75:
  77. Text Field 76:
  78. Text Field 171:
  79. Text Field 172:
  80. Text Field 68:
  81. Text Field 80:
  82. Text Field 69:
  83. Text Field 81:
  84. Text Field 70:
  85. Check Box 6: Off
  86. Check Box 8: Off
  87. Check Box 9: Off
  88. Check Box 10: Off
  89. Check Box 11: Off
  90. Check Box 12: Off
  91. Check Box 13: Off
  92. Check Box 7: Off
  93. Text Field 99:
  94. Text Field 211:
  95. Text Field 212:
  96. Text Field 220:
  97. Text Field 221:
  98. Text Field 222:
  99. Text Field 223:
  100. Text Field 224:
  101. Text Field 225:
  102. Text Field 226:
  103. Text Field 227:
  104. Text Field 230:
  105. Text Field 233:
  106. Text Field 236:
  107. Text Field 239:
  108. Text Field 228:
  109. Text Field 231:
  110. Text Field 234:
  111. Text Field 237:
  112. Text Field 240:
  113. Text Field 229:
  114. Text Field 232:
  115. Text Field 235:
  116. Text Field 238:
  117. Text Field 241:
  118. Text Field 219:
  119. Text Field 210:
  120. Text Field 213:
  121. Text Field 215:
  122. Text Field 218:
  123. Text Field 216:
  124. Text Field 217:
  125. Text Field 214:
  126. Check Box 14: Off
  127. Check Box 15: Off