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