ISBAR Worksheet Olivia Jones Jasgou1752

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ISBAR worksheet

Olivia Jones

Jasmyn Gould

Introduction Hello, my name is Jasmyn Gould (SN) RN . I’m


calling from Labor and Delivery

Situation Olivia Jones, 23 y/o, BF, ADM for severe


preeclampsia, 36 wk gestation

Background Pt is diagnosed with severe preeclampsia,


admitted 5/7/2020.
Current orders: NPO until serum lab results are
in, bed rest with bathroom privileges, BP Q1Hx2
then Q4H, T, HR, RR Q1H, breath sounds Q4H,
FHR/UC monitoring, DTR Q1H, head to toe Q4H,
continuous SpO2, IV care, ultrasound, foley
catheter, place seizure pads, minimize stimuli,
NRB mask for SpO2 <92%

Assessment VS:
BP 164/98
T 99F
RR 22
HR 110
SpO2 92%
Pt c/o visual changes, headache, and epigastric
pain
The pt has crackles in the lower lobes of the lungs
The pt has low platelets, RBCs, MCH, MCHC and
elevated creatinine, BUN, ALT/AST and has
protein in the urine >455 mg/24H
Recommendation I recommend the pt be placed on seizure
precautions and environmental stimuli be
limited, including visitors. She should continue to
be monitored for progression of preeclampsia to
eclampsia. She should be fitted for a risk for falls
pt bracelet. The pt should be educated on
condition and medications. Continue to monitor
for contractions. Monitor BP Q1H

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