maternal L&D

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EDYTH T. JAMES DEPARTMENT OF NURSING

NURS 378 Maternal Child and Women’s Health Nursing

LABOR AND DELIVERY CARE PLAN

Student Name: Date:

Student Requirement: Complete all of the information below for each patient cared for during the clinical rotation day, by consulting the patient record on the assigned unit. The initial information gathered will be hand written. Please TYPE and submit at the start of the next clinical.

Biographical Data Base:

Patient’s Initials: Age: GTPAL: Gestational Age:

LMP: EDC: PNC: Allergies:

Chief complaint/Reason for Admission:

Admitting Diagnoses: Pregnancy

Brief Medical History:

Current Medical Conditions:

Past Surgeries/Hospitalizations:

Obstetrical History:

Delivery Date:

Delivery Type:

Gest Age:

Infant Sex:

Diagnostic Tests/Sonograms (From Prenatal Record):

Type of Test:

Date:

Indication:

Laboratory Data:

Blood Type:

Hemoglobin:

Hematocrit:

RBC:

WBC:

Platelets Count:

HIV/AIDS:

RPR:

Chlamydia:

Gonorrhea:

Herpes:

HPV:

Hep SAg:

GBS:

Rubella:

Other significant history

Pathophysiology (Of Disease Process): Include classic signs and symptoms; AND patients signs and symptoms.

PATIENT PHYSICAL ASSESSMENT

General Survey:

Skin:

Mouth:

Neck:

Breasts:

Heart:

Lungs:

Peripheral vasculature (Extremities):

Neurologic:

Pelvic Exam (Stage of Labor):

Blood Pressure

Mental Status (ABCT: Appearance/Behavior/Cognition/Thought process):

HUMAN NEEDS ASSESSMENT

Data:(Assessment findings, test results, drugs)

Analysis: (What does the data mean…?)

Nursing Dx (NANDA)

(Actual or potential problem

Oxygenation:

Vital signs: T______P____R___BP____

Hgb____HCT____O2Sat____

ABGs : PH: PCO2 : PO2 : HCO:

Lung Sounds: Oxygen therapy:

Heart Sounds:

Fluids/Electrolytes:

Na: K: Ca:

Intake: Output:

Nausea/vomiting:

NPO : IVs :

Elimination:

BUN: UA Output:

Urine Character:

Last BM:

Nutrition:

Ht: Wt:

Supplements:

Blood Glucose: Albumin:

Hct: Hemoglobin:

NPO: TPN:

Type of diet:

Total intake during shift : %

Data:(Assessment findings, test results, drugs)

Analysis: (What does the data mean…?)

Nursing Dx (NANDA)

(Actual or potential problem

Rest/Comfort:

Pain: Location: Quality:

Severity: Duration:

(on a scale 0-10)

Sleep:

Normal Hours of Sleep:

Duration:

Mobility:

Activity Level:

Activity Tolerance:

Spiritual Integrity:

Religion:

Beliefs impacting on health status:

Affiliation:

Primary Care Provider/support at Home:

Family Dynamics:

Language Spoken:

Social worker/case manager:

Community resources:

Sexual Integrity:

Development status:

Reproductive organs:

Relationship with significant other:

Data:(Assessment findings, test results, drugs)

Analysis: (What does the data mean…?)

Nursing Dx (NANDA)

(Actual or potential problem r/t to patient’s status)

Safety:

WBC: C & S:

Vital signs:

Wounds/Incisions:

Hygiene needs:

Perineal laceration/episiotomy:

Pain medications:

Lochia:

Hemorrhoids:

Patient Identification:

Abuse:

Safety Concerns (Hospital and Home):

Sensation/Perception/Cognition:

Orientation:

LOC:

Neuro Assessment:

Other Findings:

Self-esteem:

Emotional status:

Mood:

Behavior:

Appearance:

Select the TOP THREE human needs and formulate a nursing diagnosis for one. Write goals and at least FIVE NURSING INTERVENTIONS AND RATIONALES to accomplish the goal for the nursing diagnosis. (Must cite either Lowdermilk/Perry or Hockenberry stating “I will ...” or “The student nurse will ...” and must relate to the Human need and the goal):

1.

2.

3.

Nursing Diagnosis

Outcomes/Goals

Nursing Interventions

Rationales

Evaluation (goal met or not met?)

Medications:

Medications/ Dose/Brand

Generic Names

Indication of use

Route

Frequency

Side effects and Adverse Effects

Nursing Considerations

IV Fluids/IV Antibiotics:

IVFluids:

Rate

Frequency

Indications of use

Developmental Stage in Life:

Teaching & Health Promotion (What educational information and some health promotion tips would you include with your care):

Evaluation of mastery of objectives set for the day (Was the Goal met or unmet? If yes, how? If not, why not and how can you meet or modify the Goal?):

Areas for professional growth (the student’s):

1

NURS 378

Revised 1/08/2020