Assignment
Formulate an ISBAR for every patient.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? Explain all RELEVANT data and use supporting citations.
Part I
One hour after Delivery:
Anne is a 17-year-old, gravida 1 para 1 who is 39 weeks gestation. She recently experienced a normal spontaneous vaginal delivery on 6/12/2020 at 2300 without the use of pain medications or an epidural. She came into labor on 3/01/2022 at 0600 stating she had broken her water yesterday at noon. She delivered a baby boy who was placed skin to skin following delivery. You assign Apgars of 8 and 9. Baby voided right after delivery and is due to stool. Weight: 7 lbs. 0 oz. (3.2 kg), 20 inches (50.8 cm) long. After he had his first feeding, erythromycin ointment was applied to his eyes. Vitamin K and hepatitis B vaccine (after consent given) were administered in right and left thigh in the outer aspect of the left thigh. Anne is Group Beta Strep (GBS) positive and received antibiotics 3 doses before delivery, blood type is B-, and rubella positive. Cord blood was sent.
Personal/Social History:
Anne has her mother with her for support. She seems to be tired but is holding and interacting with the baby appropriately. The father of the baby is not involved. Anne plans on breastfeeding for "awhile." Anne still lives at home, and her mother plans to help with the new baby and appears supportive.
Part II
Mrs. Marla Smith is a 38-year-old G3P2012 who was admitted in active labor at 39+3 weeks and had a spontaneous vaginal delivery 30 minutes ago. Her delivery was uncomplicated. She had a first-degree laceration that did not require repair. She is approximately 30 minutes postpartum and has just called out because she feels dizzy and has more bleeding.
1. She has no significant past medical history.
2. She has no known drug allergies.
3. Her pregnancy was uncomplicated except for an elevated 1-hour glucose screen with a normal 3- hour glucose tolerance test.
4. Laboratory Data (On Admission):
a. Hemoglobin:12.2
b. Hematocrit:36.6
c. WBC: 12,000
d. Platelets:218,000
5. Delivery Information
a. Measurement of cumulative blood loss (as quantitative as possible) from the delivery was 300cc.
b. The placenta was inspected at the time of delivery and appeared to be intact per the delivery note.
c. There was only a first-degree laceration that did not require repair.
d. The infant weighed 4120 grams.
e. The patient has an IV line in place with oxytocin running.
6. Mariah has been in labor for eight hours. You check her External Fetal Monitor strip and notice this pattern. What is your next step?
Part III
Susan is 42 weeks' gestation. Her pregnancy has been uneventful except for a diagnosis of gestational diabetes. She is 10 cm dilated and 100% effaced. She begins to push, the fetal head comes out and goes back in. What is this called? What do you suspect is happening? What steps would you take to deliver this baby? How may this affect the baby and why?