Ob Careplan PDF

MB Care Plan
Assessment
Student Name:
Ethnicity:
Age:
G:
Del. Mode:
Del. Date:
Del. Time:
P:
Maternal Issues:
Type/Rh:
V/S @
Infant Gender:
Apgars:
Birth wt.:
Current wt.:
Date of care:
Breast/Bottle
% change:
Neonatal Issues:
Rubella:
Hep B:
GBS:
BP
Pain
BP
Pain
Routine Maternal Medications:
Type/Rh:
V/S @
Blood sugars:
Bili:
Pain
Pain
Maternal PRNs:
1.
Due @
2.
Due @
IV/SL:
Intake:
3.
Due @
Rate:
Output:
Maternal Assessment
Neonatal Assessment
General appearance:
General appearance /activity/state /posture:
Resp:
rate
effort
BS
Cardiac: rate
sounds
Breasts: soft, filling, engorged
Nipples: everted, flat, inverted
nipple pain /breakdown
Uterus: consistency
position r/t umbilicus (cm or )
position r/t midline
Bowel:
diet
BS
flatus/stool
hemorrhoids
Bladder: palpable
urine
voiding method
Lochia: character
amount
odor
C/S incision/Perineum (laceration degree, extension = ________)
skin integrity
pain
R=
E=
E=
D=
A=
Musculoskeletal/Integumentary/Neuro:
Head:
Homans:
Environment/support:
Feeding:
sutures
fontanelles
shape/symmetry
EENT:
eyes
ears
nares
palate
Skin:
color
markings
texture/turgor
Resp:
rate
effort
Lung sounds
Cardiac: rate
rhythm
sounds
GI/Abd:
umbilical cord
Bowel sounds
abd tone/appearance
stool
GU:
genitalia
urine
Musculoskeletal:
clavicles
spine
extremities
Reflexes evaluated:
suck/swallow
quantity/frequency
average LATCH score:
L=
A=
T=
C=
H=
Care Plan (continued)

Pregnancy History
Prenatal
Labor and Delivery
Obstetric history
Labor
Prenatal care started @

LMP:
G
Onset of labor:
weeks gestation
EDB:
(T
date:
time:
Was labor induced? Y N

If yes, why?
)
What method was used?

What did your patient take for pain during labor:
Previous pregnancy history:

Rupture of membrane (ROM): date:
Course of current pregnancy

Pre-pregnant wt:
time:
SROM
Clear
AROM
Meconium
Delivery
Ht:
Admission wt:
BMI:
Total wt. gain:
Appropriate wt. gain?
Baby delivered:
Delivery method:
date:
Vag
C/S reason:
Placenta delivered:
Problems/risk factors this pregnancy:
time:
Vag Vac Vag Forceps
date:
time:
What anesthesia was used during the delivery:

Episiotomy/laceration type/degree:
none 1
Estimated blood loss (EBL):

Labor Analysis
1 stage started@
st
Allergies:
Prenatal medications:
total
latent phase began @
ended @
active phase began @
ended @
transition phase began @
ended @
2 stage started@
ended @
total
3 stage started@
ended @
total
nd
rd
Tobacco/Alcohol/Drug use:
ended @
Total length of labor:
Total length of ROM:
Pre-existing medical conditions:
What happened during your shift? What kind of care did you
provide your patient(s)? What did you do for the patient(s)?
0700 ______________________________________________
1300 ______________________________________________
0800 ______________________________________________
1400 ______________________________________________
0900 ______________________________________________
1500 ______________________________________________
1000 ______________________________________________
1600 ______________________________________________
1200 ______________________________________________
1700 ______________________________________________
CARE PLAN (continued)

Nursing Process
Develop appropriate nursing diagnoses based on your patients risks, identified problems, and your assessment. Use 3-part format
(ND, r/t, AEB). Your care plan should reflect your patients individualized needs do not submit canned or
standardized care plans.
#1 Most significant maternal problem (one)
Nursing Diagnosis (in appropriate format):
Measurable, Expected Patient Outcome w/Target date:

Measurable, Expected Patient Outcome for your shift (may be the same):
Nursing Interventions (4, only 1 that includes assessment):
Rationale (1 for each intervention):
Outcomes Achieved/Not Achieved; Evaluation:
Changes/Additions needed:
#2 Most significant newborn problem (one)


Nursing Interventions (4, only 1 that includes assessment):
Mother/Baby Shift Report

Student Nurse Name: _________________________
Mother
Age:
Allergies:
Ethnicity:
Blood type & Rh:
Antibody screen:
Rubella
VDRL(RPR)
HIV
GBS
if +, name the antibiotic and how many doses:
(T
L )
Date of admit
EDD
GA@ delivery
Date and time of delivery

Mode of delivery:
If induced, what was the indication?
SVD
VAVD
FAVD
Epis or lac? What degree?

P C/S?
VBAC
Repair?
R C/S? CS c BTL?
If primary CS, what was the indication?

Type of anesthesia or pain relief?
Analgesia?
Moms problem list and treatments/interventions:
Fundus
Lochia
Nipples
Perineum (dont forget hemorrhoids!)
Incision/dressing
Diet
IV/SL
Output (voiding/foley)
VS
Pain
Meds, including last dose
BM/BS
If close to D/C, what remains to be done?
BABY
Gender
Apgars
Weight
Length
VS: T
Assessment abnormals:
Breast or bottle
Last feed
LATCH score
Type of formula
Mec
Void
If close to DC, what still needs to be done?
Amount/time
If breast fed minutes/feed
AP
The criteria used in grading care plans reflects the expectation of complete and accurate information appropriate
to your patients history and assessed needs. Number values are to the left. Handwrite all assignments; do
not type.
CARE PLAN CRITERIA
Maternal Assessment
3
Assessment complete and correct, using appropriate terminology ( 1 element missing/incorrect)
2
Incomplete/inaccurate data, inappropriate terminology (2-4 elements)
1
Unsatisfactory/inaccurate data (5 -6 elements)
0
Unsatisfactory/inaccurate data (7 or more elements)
Neonatal Assessment
3
2
1
0
Unsatisfactory/inaccurate data
Prenatal History
3
Data complete and correct with analysis of risk factors ( 1 element missing/incorrect)
2
Incomplete/inaccurate data, (2-4 elements)
1
0
Labor and Delivery History
3
Data complete and correct ( 1 element missing/incorrect)
2
Incomplete/inaccurate data (2-4 elements)
1
0
Communication/Documentation
3
Notation provides complete, concise picture of patient history and current status
2
Notation is vague, wordy, or incomplete
1
Notation is inadequate, providing insufficient information about patient history or current status
0
Care Planning (First Diagnosis)
3
Diagnosis appropriate, outcome and interventions appropriate to diagnosis, evaluation addresses expected outcome
2
Diagnosis not directly r/t patient, canned diagnosis, or expected outcome and evaluation dont correlate
1
Inappropriate diagnosis, incomplete, doesnt follow appropriate format
0
Does not apply to patient
Care Planning (Second Diagnosis)
3
2
1
0
Presentation: spelled correctly, neat, legible, well organized
3
Legible, spelled correctly, minimal corrections, no overwritten elements (follows charting guidelines)
2
Misspellings, illegible words or scribbles making the page difficult to read & follow (2-4 elements)
1
Misspellings, illegible words or scribbles (5 -6 elements)
0
CARE PLAN GRADE:

COMMENTS:
/24
JOURNALING DAILY SHEET

Name: _________________________________________ Date of clinical care ______________
1. Today I was excited about
2. What I learned new about myself and nursing
3. Today I had trouble with
4. What worked well for me today was
Instructor comments:
Labor and Delivery (LD)

CLINICAL LOCATION
Refer to clinical orientation and schedule for details.
PREPARATION GUIDELINES
1.
2.
3.
Review theory content for caring for women during pregnancy, labor, and birth.
Review the stages of labor and birth, and common nursing interventions for perinatal clients.
Review medications administered in labor and delivery.
LEARNING OBJECTIVES
1.
2.
3.
4.
5.
6.
Evaluate the role of the nurse in the management and care of labor patients.
Identify common procedures performed by the nurse caring for active labor patients.
Recognize specific techniques used by the nurse to develop trust and facilitate communication.
Identify specific ways that the nurse serves as a patient advocate.
Discuss your observations of how the nurse facilitates Family Centered Care.
Identify initial steps in the neonatal resuscitation process
ACTIVITIES
Observation and participation in the care of an active labor patient.

Provide comfort measures and psychosocial/spiritual support for an active labor patient.
Observe a delivery and participate in the immediate recovery of a postpartum patient.
Observe RN performing tests for fetal well being and participate in the testing procedures.
Participate in activities as described on the Labor and Delivery Clinical sheet.
Review the case of at least one patient during clinical. Identify your patients areas of
risk/concern, if any, and relate them to her perinatal experience.
Assignments
1.
2.
3.
Introduce yourself to the staff. Participate in morning report and let the staff know what patient
you are interested in following. Come prepared to actively participate in the days activities.
For one patient, identify risk factors, obtain lab values, and describe her labor process and
delivery.
Turn in the completed Labor Evaluation by start of next clinical.
Dominican University of California

NURS 3100 Maternal-Newborn and Womens Health IEN
Labor & Delivery Care Plan
Labor Record
Time
10
9
8
7
6
5
4
3
2
1
FHR
UCs
VS
-4
-3
-2
-1
0
+1
+2
+3
+4
variability
baseline
s
Method
Frequency
Strength
Length
Method
BP
T
P
R
Pain
(List by half hour from beginning of shift or from patients arrival on your shift )
Note patients progress on a labor curve (Friedmans curve).
o (Mark an X for station and a for dilation)
Note the fetal heart rate (FHR) Q 30 minutes for this document
o Variability
Abs absent
Min minimal
Mod moderate
Mrk marked
o Changes
A Accelerations
D Decelerations
o Baseline heart rate in numbers ending in 0 or 5 (ex: 150, or 145)
o Method of surveillance
US ultrasound
FSE Fetal Spiral Electrode
I intermittent
C continuous
Note the uterine contractions (UCs) Q 30 minutes for this document. If none, write N
o Frequency in minutes (ex: 3-4)
o Strength
Mi mild Mo moderate S strong
o Duration in seconds (ex: 60-90)
o Method
T toco
I IUPC (Intrauterine Pressure Catheter)
VS
o BP, TPR (as often as Q 30 minutes, but no more for this document. Temperature may be Q 2-4 hours.)
o Pain (1-10 scale)
Labor Evaluation
Maternal Age:
Prenatal History:
G
(T
EDD:
Prenatal Risk Factors:
Weeks gestation:
Labor Analysis:
Graph your patients labor curve on the other side of this
sheet.
Labor & Delivery status at start of shift:

SVE:
/
/
Membranes (indicate below)
Intact
Ruptured
AROM
SROM
Date & Time:
Color of fluid:
If labor was induced (or delivery was C/S), what was the
indication?
1st stage started@

ended@
latent phase began @
active phase began @
transition phase began @
total
ended @
ended @
ended @
2nd stage
started @ ____________
ended @ _____________
total ________________
3rd stage
started @ ____________
ended @ _____________
total ________________
Admit weight _____lbs Pre-pregnant weight _____ lbs
Total length of labor: __________
Weight gain ______lbs Appropriate? Yes
Total length of ROM: __________
No
BMI _________
(___lbs x 703/ ___ht in inches2 = BMI
Example: 100 lbs x 703/602 = 19.5
Fetal Heart Rate
Changes in the pattern over time?
Yes No
Accelerations?
Decelerations?
Type: Variable
Early
Late
How did the nurse promote fetal oxygenation?
Postpartum Risk Factors:
Neonatal Risk Factors: Apgars:
Weight:
What are the priorities in care? What happened with this patient?
How did the nurse manage patient comfort?

What are this patients top two priority nursing diagnoses and why? (No need to provide interventions.)
1.
2.
Laboratory Results
Complete the normal value and implications sections for ALL tests.
Prenatal Test
Pt Test Results Normal Value What do these results mean to you in caring
for this mom and baby?
MEDICATION WORKSHEET (all scheduled meds, and any PRNs in last 48 hrs)
Allergies_____
Do not include anesthetic agents
Medication,
Safe dosage
Drug type, why Side effects
If IV,
dose, frequency, range for
ordered
recommended
route,
patient
dilution and
rate
LABOR AND DELIVERY CARE PLAN GRADING RUBRIC

The criterion used in grading care plans reflects the expectation of complete and accurate information appropriate
to your patients history and assessed needs. Point values are on the left. Assignments must be hand written in
black or blue ink, and not typed. Assignments are due at the beginning of the next clinical meeting.
Labor record
6
Notation provides complete, concise picture of mother and baby
5
Notation provides complete, concise picture of mother and baby (1 element)
1-4
Notation is vague, wordy or incomplete (2-6 elements)
0
Notation is inadequate, providing insufficient information about patient, fetus, or current
status (more than 6 elements)
Labor evaluation
6
Notation provides complete, concise picture of mother and baby
5
1-4
Notation is vague, wordy or incomplete (2-6 elements)
0
Notation is inadequate, providing insufficient information about patient, fetus, or current
status (more than 6 elements)
Laboratory values
6
Patient results, normal values, and meaning for patient care complete and correct, using
appropriate terminology
5
1-4
1
Unsatisfactory/inaccurate data (more than 6 elements)
Medications
6
Assessment complete and correct, using appropriate terminology
5
1-4
0
Unsatisfactory/inaccurate data (more than 6 elements)
CARE PLAN GRADE:

COMMENTS:
/25 POINTS

Intermediate or Neonatal Intensive Care Nursery (ICN or NICU)

CLINICAL LOCATION
Refer to clinical orientation and schedule for details.
PREPARATION GUIDELINES
1.
Review theory content for the care of high-risk infants
LEARNING OBJECTIVES
1.
2.
3.
4.
5.
Evaluate the role of the nurse in the ICN.

Identify the common procedures used in caring for the high risk neonate.
Assess the special needs of the premature infant, meconium aspiration infant, the infant suffering
from intrauterine or birth asphyxia, the drug dependent infant.
Participate in the care of a high risk infant (assessment, feeding, etc.)
Observe and discuss the role parents can assume and the teaching and support needs they have.
ACTIVITIES
Introduce yourself to the staff. Participate in morning report and let the staff know what patient you
are interested in following. Come prepared to actively participate in the days activities.
Observe and participate in the care of a high risk neonate.
Observe and develop a beginning understanding of the rationale for care provided each infant in the
ICN.
Assignments
1. Develop a care plan for your assigned infant. (See NICU Care Plan below.)
2. Completed care plan due by the beginning of the following clinical day.
Student name:
Date of care:_________________
ICN/NICU Care Plan

For one patient, provide some basic information about the maternal prenatal history, labor and delivery process, and
any identifiable risk factors pertinent to the infant. Obtain and review infant lab values, and compare with the normal
values for each test. Describe the implications of the labs in caring for this infant. Focus on anticipatory thinking.
What about her history is significant for her labor and delivery, what about her labor and delivery is significant for
newborn?
Obstetric history
Birth
Prenatal care started @

LMP:
Date of birth:
EDB:
(T
Gender:
male: _______ female: _____
weeks gestation
Maternal problems/risk factors with pregnancy:
date:
time:
Gestational Age at Birth:
wks
Corrected Gestational Age:
wks
What type of birth? NVSD: _____ CS: _________

If CS, reason: _________________________
Rupture of membrane (ROM): date:
Infants History
Course of current admission
SROM
Clear
AROM
Meconium
time:
Current assessment (refer to your computer documentation)

Neuro:
Birth wt:
Length:
FOC:
Chest::
Growth %tile:
Wt. gain/loss?
Cardio:
Diagnosis:
Respiratory:
Pathophysiology (simple terms):
GI:
GU:
Family assessment (SES, family dynamics, language, etc.):
Musculoskeletal:
Integumentary:
V/S @
O2 Sats
P
8-hr I
Pertinent labs/diagnostics
05-23-2015
BP
Pain
8-hr O
Pt Test
Results
Diet:
Normal
Value
What do these results mean to you in caring for this baby?
Medication Worksheet (all scheduled medications)

Medication, dose, frequency, route (if
IV recommended dilution and rate)
05-23-2015
Safe dosage range for

patient
Pts weight today:
Drug type, why ordered
Side effects
Nursing Process
Develop appropriate nursing diagnoses based on your patients risks, identified problems, and your assessment. Use 3-part format
(ND, r/t, AEB). Your care plan should reflect your patients individualized needs do not submit canned or
standardized care plans.
#1 Most significant neonatal problem
Nursing Interventions (4, only one of which is assessment):
#2 Second most significant neonatal and/or family problem

05-23-2015
NICU Shift Report

Student Nurse Name: _________________________
DOB
GA at birth
Corrected GA
Gender
Diagnosis
Brief history
Assessment abnormals:
VS: T
BP
Diet
Method
Intake
PO
O2 Sat
Pain
NG
IV
Output
BM
Current weight
Growth percentile
Supplemental O2
Method
Meds
scheduled
Labs/x-rays
Plan/ interventions:
05-23-2015
Type
Void
l/min
PRN
NICU/ICN Grading Rubric

The criterion used in grading care plans reflects the expectation of complete and accurate information appropriate
to your patients history and assessed needs. Point values are on the left. Assignments must be hand written in
black or blue ink, and not typed. Assignments are due at the beginning of the next clinical meeting.
CARE PLAN CRITERIA
Perinatal & Birth History
3
2
1
Unsatisfactory/inaccurate data (5-6 elements)
0
Neonatal Admission Data
3
Data is complete and correct, using appropriate terminology ( 1 element missing/incorrect)
2
1
0
Neonatal Assessment
4
3
Incomplete/inaccurate data, inappropriate terminology (2 elements)
2
1
0
Diagnostics, Labs, Medications
3
Data complete and correct with analysis of risk factors ( 1 element missing/incorrect)
2
Incomplete/inaccurate data, (2-4 elements)
1
0
Communication/Documentation
3
Notation provides complete, concise picture of patient history and current status
2
Notation is vague, wordy, or incomplete
1
Notation is inadequate, providing insufficient information about patient history or current status
0
Care Planning (First Diagnosis)
3
2
1
0
Care Planning (Second Diagnosis)
3
2
1
0
Presentation: spelled correctly, neat, legible, well organized
3
Legible, spelled correctly, minimal corrections, no overwritten elements (follows charting guidelines)
2
Misspellings, illegible words or scribbles making the page difficult to read & follow (2-4 elements)
1
Misspellings, illegible words or scribbles (5 or more elements)
0
CARE PLAN GRADE:

COMMENTS:
05-23-2015
/25

05-23-2015

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MB Care Plan

Routine Maternal Medications:

General appearance /activity/state /posture:

Care Plan (continued)

Labor and Delivery

Prenatal care started @

Was labor induced? Y N

What method was used?

Previous pregnancy history:

Course of current pregnancy

Total wt. gain:

Appropriate wt. gain?

Problems/risk factors this pregnancy:

Vag Vac Vag Forceps

What anesthesia was used during the delivery:

Estimated blood loss (EBL):

latent phase began @

active phase began @

transition phase began @

Total length of labor:

Total length of ROM:

Pre-existing medical conditions:

CARE PLAN (continued)

Measurable, Expected Patient Outcome w/Target date:

Nursing Interventions (4, only 1 that includes assessment):

Rationale (1 for each intervention):

Outcomes Achieved/Not Achieved; Evaluation:

#2 Most significant newborn problem (one)

Measurable, Expected Patient Outcome w/Target date:

Outcomes Achieved/Not Achieved; Evaluation:

Rationale (1 for each intervention):

Mother/Baby Shift Report

Blood type & Rh:

if +, name the antibiotic and how many doses:

Date and time of delivery

If induced, what was the indication?

Epis or lac? What degree?

If primary CS, what was the indication?

Moms problem list and treatments/interventions:

Perineum (dont forget hemorrhoids!)

Meds, including last dose

If close to D/C, what remains to be done?

If close to DC, what still needs to be done?

CARE PLAN GRADE:

JOURNALING DAILY SHEET

2. What I learned new about myself and nursing

3. Today I had trouble with

4. What worked well for me today was

Labor and Delivery (LD)

Observation and participation in the care of an active labor patient.

Dominican University of California

Prenatal Risk Factors:

Labor & Delivery status at start of shift:

1st stage started@

Admit weight _____lbs Pre-pregnant weight _____ lbs

Total length of labor: __________

Weight gain ______lbs Appropriate? Yes

Total length of ROM: __________

Postpartum Risk Factors:

Neonatal Risk Factors: Apgars:

How did the nurse manage patient comfort?

LABOR AND DELIVERY CARE PLAN GRADING RUBRIC

Admit weight _lbs Pre-pregnant weight _ lbs

male: ___ female: _

What type of birth? NVSD: _ CS: _____