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MaternitycareplanRN.docx
RN Maternity/Labor & Delivery Daily Clinical Assignment Sheet
Student Name: _____________________________________________ Date: _________________________________________
Mom’s Initial: ______________ Admission Date:__________________ Room number/Unit:_______________________________
Age: ____________ A llergies: ________________________________________________________________________________
Sexual Preference:__________________ Religion:_____________ Ethnicity:______________________
Patient Primary Language: ____________________________ Preferred language to learn:________________________________
How does the patient like to be addressed: ______________________________________________________________________
Physician:_________________________________________________________________________________________________
Support Person: ___________________________________________________________________________________________
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G:__________________ T:____________________ P: ____________________ A: __________________ L:_________________
Gestation:___________________________________ EDD:_________________________________________________________
Delivery Date: __________________ C/S:____________ Spont:____________ Induced:____________ Vag:__________________
MOM
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Blood Type/Rh |
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MMR:___________ Flu:_____________ Tdap:____________ Covid:_________________ Breast:_____________________________Fundus:_________________________________ Lochia________________________ Epi:______________ Laceration:_________________ Repair:_______________ Incisions:______________ Foley:_________________________ Void:___________________ Last BM:______________ Pain:________________________ Diet:___________________________ IV:_________________________________________ |
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Rub |
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RPR |
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GBS |
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HIV |
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Heart Rate |
Resp Rate |
B/P |
Spo2 |
Pain Scale (0-10) |
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Hep B |
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HSV |
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G/C |
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Rhogam |
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BABY BOY: _______ BABY GIRL: ______
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Baby’s Initial________________ DOB:__________________GA______________ APGARS:_________/__________ Birth Weight:_________ Current Weight:________ Head:_________ Chest:________ Length:_______ Abd Girth:______ Labs/Testing Blood Type:_________ Coombs Positive:____ Negative:____ NBS:____ Vitamin K:___ Erythromycin:____ Stool:____ Void:___ Neuro:_________________________________________________________________________________________________ Reflexes:_______________________________________________________________________________________________ Cardiac:_______________________________________________________________________________________________ Resp:__________________________________________________________________________________________________ Skin:__________________________________________________________________________________________________ Skin to skin:____________________________________________________________________________________________ Circumcision:___________________________________________________________________________________________ NAS Symptoms:_________________________________________________________________________________________ Complication Devices: Vacuum:________________ Forceps:_______________ Bakri ballon:__________________ |
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Heart Rate |
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Respiration |
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Temperature |
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Feeding Breast:______ Formula:_______ Both:_______ Formula Type:_______________________________________________________ Amount/Freq:_______________________________________________________________________________________________ Nipple Type:________________________________________________________________________________________________ Lactation Consult:____________________________________________________________________________________________ |
List the prescribed Medications for client; determine the acute or chronic condition for which each medication is prescribed; and side effects:
1. Drug: ____________________________ Classification: ___________________________ Reason: ___________________________
Side effects: _______________________________________________________________________________________________
Patient Teaching:_____________________________________________________________________________________________
2. Drug: __________________________ Classification: ___________________________ Reason: ____________________________
Side effects_________________________________________________________________________________________________
Patient Teaching:_____________________________________________________________________________________________
3. Drug: __________________________ Classification: ___________________________ Reason: ____________________________
Side effects__________________________________________________________________________________________________
Patient Teaching:_____________________________________________________________________________________________
4. Drug: __________________________ Classification: ___________________________ Reason: ____________________________
Side effects: _______________________________________________________________________________________________
Patient Teaching:_____________________________________________________________________________________________
Laboratory Tests
Lab Name _____________________Value ________________ Normal ____________Abnormal __________________
Lab Name_____________________ Value _________________Normal ____________Abnormal __________________
Lab Name _____________________Value _________________Normal ____________Abnormal ___________________
Lab Name _____________________Value _________________Normal ____________Abnormal____________________
What pertinent teaching needs to be completed regarding any of the concerns, treatment, or health conditions?
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Identify the client’s knowledge deficit (state the client’s knowledge deficit using the client’s words).
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Identify the stage of growth and development and appropriate milestones. (Include normal and/or abnormal behaviors).
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What modifications will you need to make related to your teaching methods based on the patient’s developmental stage, age, culture, preferences, and level of health literacy?
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Any manifestations not being addressed? What will you do about them? (Include Comorbidities)
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What are you on alert for today with this patient?
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What are the important assessments to make?
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What complications may occur? What could go wrong?
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What nursing interventions will prevent complications?
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How will you prioritize the implementation of nursing interventions? Explain.
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What actions will you take for each complication should it occur?
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Focused Care Plan
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Nursing Diagnosis
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Goals 2 Goals per Nursing Diagnosis |
Interventions 2-3 Nursing Interventions |
Rationale for Intervention |
Evaluation Relating directly back to your patient as to; Goal met, Goal partially met, Goal not met or Going ongoing. Give the reason why a goal was not met. |
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Nursing Diagnosis
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Goals 2 Goals per Nursing Diagnosis |
Interventions 2-3 Nursing Interventions |
Rationale for Intervention |
Evaluation Relating directly back to your patient as to; Goal met, Goal partially met, Goal not met or Going ongoing. Give the reason why a goal was not met. |
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List Skills Perform Today: ___________________________________________________________________________________________________
List Skills Observed Today: _________________________________________________________________________________________________
Describe how evidence-based practice was implemented. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
NURSES NOTES IN SBAR FORMAT: S- Situation
B- Background
A- Assessment
R- Recommendation
Situation____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Background______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Assesment______________________________________________________________________________________________________________________________________________________________________________________________________________
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Recommendation_________________________________________________________________________________________________________________________________________________________________________________________________________
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Instructor’s Comments: _____________________________________________________________________________________________________
Student Signature and Title: _______________________________________________ Date: ___________________________________________
Rev. 2/2024 7706 Leesburg, Pike., Suite #200, Falls Church, VA 22043 Tel: 703-891-1787 Fax: 703-891-1789 www.standardcollege.edu
