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 | |||
| 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 (vagin*l, 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 |
