NR 465 Care of Childbearing Families and Reproductive Health

NR 465 Care of Childbearing Families and Reproductive Health
Student Name: Patient Initials: ______________ SO Initials: ________________

Date(s) of care:
Patient Information (Recognizing & Analyze Cues)

G____T_____P_____A_____L_____ Multiples_______ EDD: ___________ Gestational Age____________ Maternal Age: _______
Allergies__________________________________________________________________________________________________________
Medications: ______________________________________________________________________________________________________
Pertinent Obstetrical History:

______
Pertinent Medical History: ____________________________________________________________________________________________

__________________________________________________________________________________________________________________
Occupation: ____________________________________
Family History:
Educational Level: □ High School □ College □ Masters □ Doctorate □ Other _________________
Religion:
Sociocultural considerations:
Current lab findings: Blood Type: ___________ Rh Factor: __________ Antibodies: □ positive □ negative Rubella Status:___________
GBS Status: □ positive □ negative Hepatitis: _____________ HIV:___________ Hgb/Hct:_________
Other Labs:_________________________________________________________________________________________________________
Current diagnostic findings: _
Stage in Labor:_________ Phase in Labor: _____________ Pain Relief Method? ________________Delivered?_____________
□ Vag □ C/S □ VBAC □ Boy □ Girl Weight ____________ Length ___________ Feeding Method: □ Breast □ Bottle
This tool MUST accompany your Labor and Delivery care plan and provide a basis for the nursing care in your care plan
Labor and Delivery

Fetal Monitoring Process Card (Recognizing & Analyze Cues)
Student Name:___________________________________ Allergies: __________________________________
BASELINE DATA: Stage of labor:________________ Phase of labor:_________________
Maternal History: EDC_______G_______ T______ P______A______L________ Gestational Age______ Maternal Age:_________
Important Prenatal or Medical History:_______________________________________________________________________________
Maternal VS: T________P______ R_______ BP_______/_________
Cervix: Dilation____________ Effacement__________ Station________________
Membranes: Intact_____ AROM (time)_____SROM (time)_____Color_________ Odor:_________ Amount:___________
Fetal presenting part:________ Position ________ Lie__________
Medications (type, dose, route, time):___________________________________________________________________________________
Pain Relief being utilized:____________________________________________________________________________________________
ASSESSMENT: Contractions: (TOCO)_______________ (IUPC)__________
Frequency__________ Duration___________ Intensity____________ Resting Tone_______________
Fetal Heart Rate: (US)______________ (FSE)________________ Baseline_____________ Variability □ absent □ minimal □ moderate □ marked
Periodic/Episodic changes:_________________Early Decels__________ Late Decels_____ Variable Decels_____ Prolonged Decels __________
Accelerations____________ NICHD Category: □ Category I □ Category II □ Category III

NURSING INTERVENTION(S): (Take Action)
Position change: ______________________
Oxygen per non-rebreather mask____________ Amount:_____________
Hydrate/Fluid Bolus_________________ Type of fluid:____________________________
DC or decrease oxytocin____________ Tocolytic?_________ Type/Dose:_____________________________________________
Call for consult with CNM/MD____________
Continue observation_____________
Response to Interventions_________________________________________________________________________________________
*adapted from Mahley, Witt, & Beckmann (1999). Teaching nursing students to critically evaluate electronic fetal monitor tracings. Journal of Obstetrics, Gynecologic and
Neonatal Nursing, Vol. 36(2), 237-240.
Assessment Nursing Diagnosis Goals & Expected Outcomes Nursing Interventions Rationale for interventions Evaluation
(Supporting data) (does not have to be a NANDA (Realistic, timed, measurable) (Strategies or actions for care) (one for each intervention) (Client’s response to nursing actions
Recognition of Cues diagnostic statement) Prioritize the Hypothesis & (3 for each diagnosis) & progress toward achieving
Analysis of Cues Generate Solutions Take Actions goals & outcomes)
Evaluate the Outcomes
Subjective:
Objective:
Subjective:
Objective:
Assessment Nursing Diagnosis Goals & Expected Outcomes Nursing Interventions Rationale for interventions Evaluation
(Supporting data) (does not have to be a NANDA (Realistic, timed, measurable) (Strategies or actions for care) (one for each intervention) (Client’s response to nursing actions
Recognition of Cues diagnostic statement) Prioritize the Hypothesis & (3 for each diagnosis) & progress toward achieving
Analysis of Cues Generate Solutions Take Actions goals & outcomes)
Evaluate the Outcomes
Subjective:
Objective:

NR 465 Care of Childbearing Families and Reproductive Health

Uploaded by

Copyright:

Available Formats

NR 465 Care of Childbearing Families and Reproductive Health

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

NR 465 Care of Childbearing Families and Reproductive Health

Uploaded by

Copyright:

Available Formats

NR 465 Care of Childbearing Families and Reproductive Health

Student Name: Patient Initials: ______________ SO Initials: ________________

Patient Information (Recognizing & Analyze Cues)

Pertinent Obstetrical History:

Pertinent Medical History: ____________________________________________________________________________________________

Educational Level: □ High School □ College □ Masters □ Doctorate □ Other _________________

GBS Status: □ positive □ negative Hepatitis: _____________ HIV:___________ Hgb/Hct:_________

Current diagnostic findings: _

Stage in Labor:_________ Phase in Labor: _____________ Pain Relief Method? ________________Delivered?_____________

Labor and Delivery

Student Name:___________________________________ Allergies: __________________________________

BASELINE DATA: Stage of labor:________________ Phase of labor:_________________

Maternal History: EDC_______G_______ T______ P______A______L________ Gestational Age______ Maternal Age:_________

Important Prenatal or Medical History:_______________________________________________________________________________

Maternal VS: T________P______ R_______ BP_______/_________

Cervix: Dilation____________ Effacement__________ Station________________

Membranes: Intact_____ AROM (time)_____SROM (time)_____Color_________ Odor:_________ Amount:___________

Fetal presenting part:________ Position ________ Lie__________

Medications (type, dose, route, time):___________________________________________________________________________________

Pain Relief being utilized:____________________________________________________________________________________________

ASSESSMENT: Contractions: (TOCO)_______________ (IUPC)__________

Frequency__________ Duration___________ Intensity____________ Resting Tone_______________

Accelerations____________ NICHD Category: □ Category I □ Category II □ Category III

You might also like

Student Name: Patient Initials: SO Initials: __

GBS Status: □ positive □ negative Hepatitis: _______ HIV:_ Hgb/Hct:_____

Stage in Labor:___ Phase in Labor: _ Pain Relief Method? Delivered?___

Student Name:_ Allergies:

BASELINE DATA: Stage of labor: Phase of labor:_

Maternal History: EDC___G_ T PAL Gestational Age Maternal Age:_______

Maternal VS: T____P R_ BP_/_______

Cervix: Dilation Effacement Station______

Membranes: Intact___ AROM (time)_SROM (time)_Color___ Odor:_ Amount:_______

Fetal presenting part: Position Lie__

ASSESSMENT: Contractions: (TOCO)_____ (IUPC)

Frequency____ Duration_ Intensity Resting Tone_______