Patient Report: Brown, Rachel
SBAR Hand-Off
Current day and time:
Friday 0300
Situation
Name:
Rachel Brown
Age:
38
Provider:
Janet Holloway, MD
Admission Diagnosis:
Preeclampsia; Induction of Labor
Pertinent medical
history:
Patient is a 38-year-old gravida 1 para 0 Caucasian female at 39 weeks gestation. She was seen in her
physician’s office Thursday morning for a nagging headache that was not relieved with acetaminophen.
BP elevated during visit; 3+ DTRs, no clonus; generalized edema; proteinuria of 2+; 60-lb weight gain
during pregnancy. She was started on IV magnesium sulfate on Thursday at 1600.
Pertinent social history:
Married, lives with husband; is an elementary school principal.
Allergies:
No Known Allergies (NKA)
Code status:
Full Code
Vital signs, (most
recent)
Time:
0045
T:
Pain
Rating:
2
Most recent pain
medication:
None (denies the need)
Oxygen therapy:
Mode:
Room air
Not applicable
Recent medication
Magnesium sulfate dose is at 1 g/hr because patient exhibited hypersensitivity to the medication
approximately 2 hours after the loading dose.
IVs:
Site:
Background:
Admission Day and Time:
Gender:
Left
forearm
Female
Type:
98.6 F
(37 C)
Ethnicity:
B/P:
LPM:
18-guage
peripheral IV
Thursday 1400
Caucasian
168/106
Assessment:
P:
Religion:
92
Patent,
infusing
RR:
Fluid:
20
Baptist
O2
Sat:
99%
FHR:
145
Time:
Lactated Ringer’s
solution infusing at 75
mL/hr with magnesium
sulfate at 25 mL/hr
Drains and Tubes:
Site:
None
Type:
Not
applicable
Assessment:
Not applicable
Wounds:
Site:
None
Type:
Not
applicable
Assessment:
Not applicable
ADLs:
Diet:
Ice chips only
Activity:
Complete bed rest
Restrictions:
Isolation:
Standard precautions
Fall risk:
Low
Assessments:
Labor
progression:
Her contraction pattern is adequate; every 2-3 minutes lasting 50-60 seconds,
moderate to strong intensity. Her cervical exam at 2300 = 3/100/-1, membranes
intact.
Neurologic:
Alert and oriented
Cardiac:
Regular rate and rhythm
Respiratory:
Lung sounds clear throughout
GI/GU:
Active bowel sounds in all quadrants. Last stool - yesterday morning / patent Foley
catheter with clear yellow urine.
Integumentary:
Warm, dry, intact
Ortho/Mobility:
No limitations identified.
Psychosocial:
Pleasant, cooperative. Low anxiety.
Other:
Labs and diagnostics:
Lab results are consistent with preeclampsia. Renal function tests indicate compromise (Cr 1.8, BUN 22,
Uric acid 7.9); liver enzymes indicate compromise (AST 38); albumin is low (2.8); platelets are low
(118,000); PT and PTT are high; and WBCs are high (21,000). Hemoglobin is 14.4 and Hematocrit is 32.
Urine was positive for protein (2+) during clinic check yesterday.
Assessment
Nurse's Assessment:
The patient and fetus are stable. Denies vision changes, epigastric pain, nausea, or vomiting. The
patient and husband have been planning for a natural childbirth and had wished to avoid medications
during labor. They are upset about everything that is happening.
Recommendation
Plan of Care:
Continue to monitor patient; Provide support to patient and family;
Tests/results pending:
None
Orders pending
completion:
Monitor intake and output hourly.
Other: