Isbar post partum newborn and bsn level 3 direct patient care

Sep 11, 2023

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

I
Introduce yourself

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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

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YEAR TYPE OF DELIVERY LABOR LENGTH COMPLICATIONS

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