| New Professions Technical Institute | |||||||
|
| |||||||
| ASSOCIATE SCIENCE IN NURSING | |||||||
| CLINICAL WORKSHEET: MATERNITY NURSING PROCESS CARE PLAN | |||||||
| STUDENT NAME |
| DATE |
| ||||
| Client Initials |
| Culture/Ethnicity |
| Support System | |||
| Unit |
| Room/Bed |
| Religion |
|
| |
| Age |
| Sex |
| Language |
|
| |
| Pre-preg Wt |
| Pre-preg Ht |
| Marital Status |
| Children & Ages | |
| Current Wt |
| Current Ht |
| Occupation |
|
| |
| G | T | P | A | L | Health Insurance |
|
|
|
|
|
|
|
| Current Work Status |
|
|
| Current Medical Diagnosis |
|
| Name of Significant Other/Primary Caregiver | ||||
|
| Highest Grade Completed |
|
| ||||
|
| Pain Rating, Quality & Location |
| |||||
| Infant Feeding |
|
|
| ||||
| Date/Time of Delivery |
| Delivery Type (Vaginal, Cesarean**, Forceps, Vacuum) |
| ||||
|
|
| **Reason for Cesarean |
| ||||
| Diagnostic procedures |
| ||||||
| Surgical procedures |
| ||||||
| Pathophysiology/Psychopathology (List Reference) | |||||||
| Reference |
Today’s Assessment
| M |
| Admissions Vital Signs | |||||
| A |
| T |
| Frequency | |||
| B |
| P |
|
| |||
| U |
| R |
|
| |||
| BB |
| B/P |
|
| |||
| L |
| Allergies/Side Effects | |||||
| E |
|
| |||||
| H |
|
| |||||
|
| Brief Health History | Diet with Rationale | |||||
|
|
|
| |||||
| Time |
| Flowsheet Notes | Activity Order | ||||
|
|
|
|
| ||||
|
|
|
|
| ||||
|
|
|
|
| ||||
|
|
|
|
| ||||
|
|
|
| Limitations/Prosthetic Device | ||||
|
|
|
|
| ||||
|
|
|
|
| ||||
|
|
|
|
| ||||
|
|
|
|
| ||||
|
| PERTINENT LABORATORY DATA |
| |||||
| Lab T | est # 1 |
| Lab Test # 2 |
| Lab Test # 3 |
| Lab Test # 4 |
| Hgb/Hct #1 |
|
|
|
|
|
|
|
| Hgb/Hct #2 |
|
| Results |
| Results |
| Results |
| Hgb/Hct #3 |
|
|
|
|
|
|
|
| . |
|
|
|
|
|
|
|
| Rationale for ab | normal results |
| Rationale for abnormal results |
| Rationale for abnormal results |
| Rationale for abnormal results |
.
1
OLUTION #
INTRAVENOUS S
INTRAVENOUS SOLUTION #2
Type
n IV)
Lactate Ringers’ (mai
Type
)
ml NS (piggyback
500
cc/hr
125
gtts/min
cc/hr
gtts/min
milliunits/minute via pump
2
Additives
Additives
U Oxytocin
30
Rationale for solution
Rationale for solution
.
| Medication Name Generic/Trade | Classification | Major Actions (why taking meds) | Dose/ Route Safe Range | Adverse Effects | Nursing Implications |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Assessment Data Subjective/Objective | Nursing Diagnosis | Plan Outcome Criteria (Client Centered) | Interventions (Nurse Centered) | Rationale for Interventions (REFERENCED) | Evaluation |
|
|
|
|
|
|
|
| Assessment Data Subjective/Objective | Nursing Diagnosis | Plan Outcome Criteria (Client Centered) | Interventions (Nurse Centered) | Rationale for Interventions (REFERENCED) | Evaluation |
|
|
|
|
|
|
|
2
2