ISBAR Preeclampsia.docx

ISBAR Preeclampsia.docx - I Introduce Yourself S Situation...

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I Introduce Yourself Your Name: Your Title: Student Nurse Reason for Being There: Nursing Care S Situation Patient: Katherine Klein Age: 25 Gender: F Height/ Weight: 160 cm (63 in)/ 61 kg (135 lb) Allergies: NKA Code Status: Privacy: Time: 0931 Attending Physician: Kelly Hunt Patient Chief Complaint: Headache, blurred vision, vomiting, nausea, epigastric pain Chief Informant: patient Family History: B Background Past Medical History: newborn male delivered via uncomplicated vaginal delivery after 12 hours of labor @40 weeks gestation Current Medications: Prenatal vitamins 1 tab PO every day Magnesium sulfate 4 grams IV bolus Hydralazine 5 mg IV bolus PRN Calcium gluconate 1 gram IV bolus PRN magnesium toxicity Hydralazine 5 mg IV bolus PRN for BP greater than 140/100 IV Therapy Magnesium sulfate IV at 2 gram/hr Lactated Ringer’s IV at 125 mL/hr Social History: A Assessment Vital Signs: 1145: B/P:162/98 HR: 92 RR: 22 Temp: 98.6 SPO2: 97% Pain: 1200: B/P:160/100 HR: 100 RR: 24 Temp: 98.6 SPO2: 97% Pain: 8/10 1220: B/P:162/100 HR: 94 RR: 22 Temp: 98.6 SPO2: 97% Pain: 8/10 1230: B/P:162/100 HR: 98 RR: 24 Temp: 97.7
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