Isbar post partum newborn and bsn level 3 direct patient care
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