NR 327 Antepartum/Intrapartum ISBAR
Student Name
Chamberlain University
NR-327: Maternal-Child Nursing
Prof. Name
Date
ISBAR Report – Antepartum/Intrapartum Case Study (2021)
Situation
Date/Time: 0700, 2021
Patient Initials: M.F., a 26-year-old gravida 2, term 1, preterm 0, abortion 0, living 1 (G2T1P0A0L1).
Estimated Date of Confinement (EDC): June 29
Last Menstrual Period (LMP): September 22
Gestational Age: 34 weeks and 5/7 days.
Pregnancy Type: Singleton.
Reason for Admission: Abdominal pain accompanied by vaginal bleeding.
Fetal Movement: Present.
Membrane Status: Intact. No rupture reported.
Allergies: No known allergies (NKA).
Attending Physician: Dr. Duran Rio.
Background
Obstetric History
| Year | Type of Delivery | Length of Labor | Complications |
|---|---|---|---|
| 2019 | Vaginal | 24 hours | None |
Current Pregnancy
- Prenatal Care: Yes
- Group B Streptococcus (GBS) Status: Negative
- Intention to Breastfeed: Yes
- Relevant Laboratory Orders: PT/INR, CBC, drug toxicology, urinalysis, blood alcohol concentration (BAC), basic metabolic panel (BMP), PT/aPTT, blood type, and crossmatch.
- Current Complications: Vaginal bleeding with abdominal pain.
- Past Complications: None.
Medical History
- Appendectomy at age 12.
- First pregnancy resulted in a vaginal delivery without complications.
Social History and Support System
- Resides with boyfriend and their two-year-old child.
- Reports domestic partner abuse (positive abuse screen).
Home Medications
- Prenatal vitamins, taken daily.
Assessment
Vital Signs and Pain Scores
| Temp (°F) | BP | HR | RR | SpO₂ | Pain | FHTs |
|---|---|---|---|---|---|---|
| 99.0 | 104/54 | 98 | 24 | 100% | 4/10 | 160 |
| 98.6 | 116/88 | 96 | 22 | 100% | 5/10 | 158 |
NR 327 Antepartum/Intrapartum ISBAR
Labor and Vaginal Examination
- Labor Status: Latent phase.
- Contractions: Every 15 minutes, lasting 20 seconds, mild in intensity.
- Fetal Heart Rate Pattern: Reassuring.
- Blood Loss: Heavy vaginal bleeding, dark red in color, no clots.
- Vaginal Exam Findings: Not applicable (no cervical details documented).
Physical Examination
- Patient alert and oriented x4, appearance appropriate but mildly anxious.
- Skin warm and dry.
- Abrasions and erythema present on the abdomen.
- Ecchymosis noted: left upper arm (3 cm in diameter) and left shoulder (10 cm length) in various stages of healing.
- Indwelling urinary catheter draining clear yellow urine.
Laboratory Results
- PT: 25 seconds (slightly prolonged).
- aPTT: 45 seconds (slightly prolonged).
- Urine toxicology: Positive for cocaine use within the last 7 days.
- Blood type: O positive.
- Hematocrit: 35%.
- CBC and metabolic panel within normal limits.
Medications and Interventions
- Betamethasone 12 mg IM once.
- Nalbuphine 10 mg IV once, then 10 mg IV every 2 hours PRN for pain.
- Ondansetron 4 mg IV every 8 hours PRN for nausea.
- IV fluids: 2000 mL bolus via 18-gauge in right antecubital vein.
- Bedrest initiated; nothing by mouth (NPO).
Recommendations
- Maintain strict bedrest to reduce risk of spontaneous rupture of membranes.
- Refer to social work for domestic violence intervention and safety planning.
- Photograph and document all physical injuries.
- Provide patient education on risks associated with illicit drug use, emphasizing abstinence without physician supervision.
Plan of Care
Nursing Analysis / Priority Diagnosis
Diagnosis: Deficient fluid volume related to excessive vascular loss as evidenced by decreased blood pressure.
Patient Goal: Patient will demonstrate stable blood pressure, heart rate, urine specific gravity, and neurological status within normal limits.
Outcome Criteria: Evidence of improved fluid balance with stable vital signs.
Priority Nursing Interventions
| Intervention | Rationale | Evaluation |
|---|---|---|
| 1. Assess history of blood loss (amount, duration, characteristics, clot presence). Instruct on pad count and weighing (1 g ≈ 1 mL blood). | Quantification of blood loss supports accurate diagnosis and guides treatment. | Blood loss controlled; dark red blood without clots. |
| 2. Monitor uterine activity, fetal status, and abdominal tenderness. | Helps differentiate between causes of hemorrhage such as placental abruption or ectopic rupture. | Ultrasound revealed 20% placental abruption; blood typing completed for potential transfusion. |
| 3. Initiate lateral recumbent bedrest. | Improves uteroplacental blood flow and reduces uterine irritability. | Patient maintained on strict bedrest; injuries caused by partner’s abdominal trauma addressed with safety measures. |
| 4. Monitor labs: CBC, type/crossmatch, Rh titer, fibrinogen, platelet count, PT, aPTT, HCG. | Assesses severity of blood loss and identifies possible coagulation disorders. | Hgb/Hct, RBC, platelets normal; PT 25, aPTT 45 (slightly prolonged). |
| 5. Maintain indwelling catheter. | Ensures monitoring of renal perfusion and fluid balance. | Clear yellow urine output; renal function tests within normal limits. |