Olivia Jones care plan Vsim
eduarmiguelrojas
MATERNALCAREPLAN.docx
|
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 Test # 1 |
|
Lab Test # 2 |
|
Lab Test # 3 |
|
Lab Test # 4 |
||
|
Hgb/Hct #1 |
|
|
|
|
|
|
|
|
|
Hgb/Hct #2 |
|
|
Results |
|
Results |
|
Results |
|
|
Hgb/Hct #3 |
|
|
|
|
|
|
|
|
|
. |
|
|
|
|
|
|
||
|
Rationale for abnormal results |
|
Rationale for abnormal results |
|
Rationale for abnormal results |
|
Rationale for abnormal results |
||
|
|
|
. |
|
|
|
|
||
|
INTRAVENOUS SOLUTION #1 |
|
INTRAVENOUS SOLUTION #2 |
||||||
|
Type |
Lactate Ringers’ (main IV) |
|
Type |
500 ml NS (piggyback) |
||||
|
cc/hr |
125 |
gtts/min |
|
|
cc/hr |
|
gtts/min |
2 milliunits/minute via pump |
|
Additives |
|
|
Additives |
30 U Oxytocin |
||||
|
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 |
|
|
|
|
|
|
|
