Sbar-labor-delivery-report-hand-off-sheet-and-assessment-tool-110411-update.pdf 5c23u

EVC Labor & Delivery Report (Hand-off) Sheet Date of Care________ Student Name______________

S

Patient______ Room_____ Age_____ Staff RN______________ Gravida_____Para____T____P____A____L____LMP_____ EDC______ EGA_____ itting diagnosis: (Circle) Spontaneous Labor/Induction/Augmentation/C/S

B

Indication for Induction/C/S: _________________________________

Allergies __________________ History/Complications _____________________________________________ Lab(Hgb & Hct) _________/_________ Platelets___________ Other_____________ Prenatal Labs: Bld Type/Rh ________ Rubella_______ VDRL/RPR______ Hep B_______ HIV________ Gonorhea________ Chlamydia_________ STI's_________Group B Strep(+/-) treated? (antibiotics/#doses) ___________/___________/___________ Prenatal record reviewed _____ Medical history: (Chronic illnesses/surgeries) __________________________ Total Wt. gain _________ BMI________ Previous Pregnancy History: Date ______ (Vaginal or C/S) Labor duration ______ Sex ______ Infant Wt. ________ Complications ________________ Meds/Herbal supplements _________________________ Pregnancy Complications _____________________________________________________ Psych/Social ____________________________________ Significant Other/Family ______________________________________________________ Childbirth Preparation/Plan ______________________________________ Infant Feeding Plan (Breast/Bottle) ________________________________

A

Maternal VS: T_____ P_____ BP_____ R_____ Current Pain_____ Tolerable Pain Level_____ Last/Current Pain Medication (time)/Score_____/_____/ _____ Voiding______ Activity__________ Dil_____ Eff_____ Sta_____ ROM:Time/Color_________

Monitor: Internal/External (Circle) Contrx:

Freq______ Duration______ Intensity______ Fetal Presentation________ Position__________ FHR______ Variability_______ Periodic Changes: Decels______ (Early, Late, Variable) Accels______ IV fluids_________ O2_______ Prostaglandins (Cervical ripening)_________________________ Oxytocin (Pitocin) Initiation time ______________Units/Rate ____________________ Analgesia/Anesthesia (type) ___________________________ Last dose ________________ Scheduled meds (antibiotics/other) ___________________________________________________________________

R

VS/Assessments/Interventions? _______________________________ Pain Management? __________________________ Foley Catheter?________

Student Schedule Break_________ Lunch________ Clinical Conference ________________ Report off to Instructor _______ Report off to Staff RN __________ Notes

Adapted 01/19/17 from Research College of Nursing Mother-Baby Care Report (Hand-off) Form obtained from QSEN (SMachado, RNc-OB, MS)

History/Assessments

Evergreen Valley College

Comfort Interventions: Activity order ____________________Relaxation techniques _________________________ ________ Warm blankets _______________ Cool wash cloth __________ Pericare __________________ Backrub __________________ Distractions __________ Conversation/friends-family ________________________________________________ Music ______ aromatherapy ______________acupuncture/acupressure ____________ Rocking chair/ birthing ball ______ Jacuzzi _________ Analgesia/narcotics (type) __________________ Analgesia/Anesthesia (regional/Epidural/Spinal) ______________________ __ Delivery Information: Infant: Date _____________Time ____________ (Vaginal or C/S) _________Vacuum or forceps ________________________ Placenta: Time __________ Spontaneous or manual extraction ___________ Placental abnormalities _________________ ___ Length of Stage I _________ Stage II ___________ Stage IIII ____________ Estimated Blood Loss (EBL) ______________ __ Newborn Birth Assessments: Apgars: 1 min 5 min 1. Heart Rate _____ _____ 2. Respiratory Effort _____ _____ 3. Muscle Tone _____ _____ 4. Reflex Responses _____ _____ 5. Color _____ _____ Total Score: _____ _____ Resuscitation: Blow-by O2_____________PPV_____________ Sex: male or female Estimated Gestational Age__________ Voided at delivery _______Meconium stool at delivery _______ Vernix noted? ___ Lanugo noted? __ No. of cord vessels _____ Gross anomalies: ____________________________________

Stage IV (Maternal Recovery Assessments @ 1 hour PP) TPR __________________________ BP _____________ Fundus _____________ Lochia ____________________ Perineum (REEDA) ______________________________ Lacerations/tears ________________ Epis ____________ C/S incision dressing _____________________________ Bladder: Voiding _______________ Foley ____________ Breath Sounds __________________________________ IV ____________________________________________ Lower ext movement/sensation _____________________ Infant /family ______________________________ Breastfeeding attempt ____________________________

Prioritized Problems/Diagnoses for Labor and Delivery 1. _____________________________________________ _____________________________________________ 2. _____________________________________________ _____________________________________________ 3. _____________________________________________ _____________________________________________

Strategies/Interventions for Labor and Delivery 1. ______________________________________________ ______________________________________________ 2. ______________________________________________ ______________________________________________ 3. ______________________________________________ ______________________________________________

Outcomes of care: Evaluation/Patient Responses: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________