NR 327 Antepartum/Intrapartum ISBAR

Student Name

Chamberlain University

NR-327: Maternal-Child Nursing

Prof. Name:

Date

Patient Case Report: Antepartum/Intrapartum Care

Chamberlain College of Nursing
NR 327 Antepartum/Intrapartum ISBAR

Patient Information and Admission Details

Patient Initials: K.K
Age: 25
Gravida/Para: G1T0P0A0L0
Gestational Age: 27 weeks (singleton pregnancy)
Reason for Admission: Sudden increase in weight gain, nausea, vomiting, blurred vision, and headache.
Membrane Status: Intact
Fetal Movement: Present
Attending Physician: Dr. Hunt Kelly

Relevant Medical History:

Past Pregnancies: None
Prenatal Care: Yes
GBS Status: Negative
Complications in Current Pregnancy: Preeclampsia
Labs Ordered: Rh antigen, CBC, urinalysis, CMP, blood type, uric acid.

Maternal and Fetal Status

Time	Temp.	B/P	HR	RR	SpO₂	Pain	FHTs
1:45 PM	36.9°C	162/98	92/min	22/min	92% (10L O₂)	8/10	140
12:00 PM	37.0°C	160/100	100/min	24/min	97%	8/10	120
12:20 PM	37.0°C	162/100	94/min	22/min	97%	8/10	124

Maternal Assessment:

Labor Status: Not in labor; no vaginal exams performed.
Urine Protein: Present.
Deep Tendon Reflexes (Achilles): 3+ bilaterally.
Physical Symptoms: Right upper quadrant pain, nausea, vomiting, blurred vision, headaches, visual disturbances, epigastric pain, facial edema, and 3+ pedal edema.

Interventions and Medications:

IV Therapy: Lactated Ringer’s at 125 mL/hr.
Current Medications:
- Prenatal vitamins
- Hydralazine 5 mg IV
- Magnesium sulfate 4 g IV bolus, followed by 2 g/hour IV infusion
- Sodium chloride IV
- Calcium gluconate 1 g IV bolus

Plan of Care and Discharge Planning

Category	Intervention	Rationale
Monitoring	Continuous maternal and fetal monitoring.	Detect changes in vitals and prevent complications of preeclampsia.
Medications	Administer antihypertensives and magnesium sulfate.	Manage blood pressure and prevent eclampsia-related seizures.
Activity Restrictions	Maintain bed rest.	Reduce risk of worsening hypertension or preeclampsia complications.
Education	Educate on preeclampsia warning signs.	Enable timely patient action for symptoms like blurred vision or swelling.
Follow-Up	Schedule routine clinical visits.	Ensure ongoing management of preeclampsia and maternal-fetal health.

Discharge Instructions:

Contact the provider immediately if symptoms such as abdominal pain, nausea, vomiting, swelling, blurred vision, or reduced urine output occur.
Adhere to prescribed antihypertensives (e.g., hydralazine).
Follow up with prenatal appointments as scheduled.

References

American College of Obstetricians and Gynecologists. (2020). Preeclampsia and hypertension in pregnancy: Guidelines and management.