MB Care Plan Assessment Student Name: Date of care:

Ethnicity: Age: G: P: Infant Gender: Apgars: Breast/Bottle

Del. Mode: Del. Date: Del. Time: Birth wt.: Current wt.: % change:

Maternal Issues: Neonatal Issues:

Type/Rh: Rubella: Hep B: GBS: Type/Rh: Blood sugars: Bili:

V/S @ T P R BP Pain

T P R BP Pain

V/S @ T P R Pain

T P R Pain

Routine Maternal Medications: Maternal PRNs:

1. Due @ /

2. Due @ / IV/SL: Intake:

3. Due @ / Rate: Output:

Maternal Assessment Neonatal Assessment

General appearance:

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:

Homans:

Environment/support:

General appearance /activity/state /posture:

Head: 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:

Feeding: suck/swallow

quantity/frequency

average LATCH score:

L= A= T= C= H=

Care Plan (continued) Pregnancy History Prenatal Labor and Delivery

Obstetric history

Prenatal care started @ weeks gestation

LMP: EDB:

G P (T P A L )

Previous pregnancy history:

Labor

Onset of labor: date: time:

Was labor induced? Y N

If yes, why?

What method was used?

What did your patient take for pain during labor:

Rupture of membrane (ROM): date: time:

SROM Clear

AROM Meconium Course of current pregnancy

Pre-pregnant wt: Ht:

Admission wt: BMI:

Total wt. gain: Appropriate wt. gain?

Problems/risk factors this pregnancy:

Allergies:

Prenatal medications:

Tobacco/Alcohol/Drug use:

Pre-existing medical conditions:

Delivery

Baby delivered: date: time:

Delivery method: Vag Vag Vac Vag Forceps

C/S reason:

Placenta delivered: date: time:

What anesthesia was used during the delivery:

Episiotomy/laceration type/degree: none 1 2 3 4

Estimated blood loss (EBL):

Labor Analysis

1st stage started@ ended @ total

latent phase began @ ended @

active phase began @ ended @

transition phase began @ ended @

2nd stage started@ ended @ total

3rd stage started@ ended @ total

Total length of labor: Total length of ROM:

What happened during your shift? What kind of care did you provide your patient(s)? What did you do for the patient(s)? 0700 ______________________________________________

0800 ______________________________________________

0900 ______________________________________________

1000 ______________________________________________

1200 ______________________________________________

1300 ______________________________________________

1400 ______________________________________________

1500 ______________________________________________

1600 ______________________________________________

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 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:

Mother/Baby Shift Report

Student Nurse Name: _________________________

Mother Age: Allergies: Ethnicity:

G P (T P A L ) Blood type & Rh: Antibody screen:

Rubella VDRL(RPR) HIV

GBS if +, name the antibiotic and how many doses:

Date of admit EDD GA@ delivery

Date and time of delivery If induced, what was the indication?

Mode of delivery: SVD VAVD FAVD VBAC

Epis or lac? What degree? Repair?

P C/S? R C/S? CS c BTL?

If primary CS, what was the indication?

Type of anesthesia or pain relief? Analgesia?

Fundus Lochia Nipples

Incision/dressing

Diet IV/SL Output (voiding/foley) BM/BS

VS Pain Meds, including last dose

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

BABY

Gender Apgars Weight Length VS: T AP R

Assessment abnormals:

Breast or bottle Last feed Amount/time

LATCH score Type of formula If breast fed minutes/feed

Mec Void

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

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 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

Prenatal History

3 Data complete and correct with analysis of risk factors ( 1 element missing/incorrect) 2 Incomplete/inaccurate data, (2-4 elements) 1 Unsatisfactory/inaccurate data (5 -6 elements) 0 Unsatisfactory/inaccurate data

Labor and Delivery History

3 Data complete and correct ( 1 element missing/incorrect) 2 Incomplete/inaccurate data (2-4 elements) 1 Unsatisfactory/inaccurate data (5 -6 elements) 0 Unsatisfactory/inaccurate data

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 Unsatisfactory/inaccurate data

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 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

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 Unsatisfactory/inaccurate data

CARE PLAN GRADE: /24 COMMENTS:

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. Review theory content for caring for women during pregnancy, labor, and birth.

2. Review the stages of labor and birth, and common nursing interventions for perinatal clients.

3. Review medications administered in labor and delivery.

LEARNING OBJECTIVES

1. Evaluate the role of the nurse in the management and care of labor patients.

2. Identify common procedures performed by the nurse caring for active labor patients.

3. Recognize specific techniques used by the nurse to develop trust and facilitate communication.

4. Identify specific ways that the nurse serves as a patient advocate.

5.

6. 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 prisk/concern, if any, and relate them to her perinatal experience.

Assignments

1. Introduce yourself to the staff. Participate in morning report and let the staff know what patient

you are

2. For one patient, identify risk factors, obtain lab values, and describe her labor process and

delivery.

3. Turn in the completed Labor Evaluation by start of next clinical.

Dominican University of California

NURS 3100 Maternal - Health IEN

Labor & Delivery Care Plan

Labor Record Time

10 9 -4 8 -3 7 -2 6 -1 5 0 4 +1 3 +2 2 +3 1 +4

FHR variability

baseline

Method

Frequency

Strength

Length

Method

VS BP

T

P

R

Pain

(List by ha )

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 o Method of surveillance

US ultrasound FSE Fetal Spiral Electrode I intermittent C continuous

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

Prenatal History:

G P (T P A L )

Maternal Age:

EDD: Weeks gestation:

Prenatal Risk Factors:

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?

Admit weight _____lbs Pre-pregnant weight _____ lbs

Weight gain ______lbs Appropriate? Yes No

BMI _________

(___lbs x 703/ ___ht in inches2 = BMI

Example: 100 lbs x 703/602 = 19.5

Labor Analysis:

sheet.

1st stage started@ ended@ total

latent phase began @ ended @

active phase began @ ended @

transition phase began @ ended @

2nd stage

started @ ____________

ended @ _____________

total ________________

3rd stage

started @ ____________

ended @ _____________

total ________________

Total length of labor: __________

Total length of ROM: __________

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 pat s 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 sc in last 48 hrs)

Allergies_____

Do not include anesthetic agents

Medication,

dose, frequency,

route,

Safe dosage

range for

patient

Drug type, why

ordered

Side effects If IV,

recommended

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 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)

Laboratory values

6 Patient results, normal values, and meaning for patient care complete and correct, using

appropriate terminology

5 Notation provides complete, concise picture of mother and baby (1 element)

1-4 Incomplete/inaccurate data, inappropriate terminology (2-6 elements)

1 Unsatisfactory/inaccurate data (more than 6 elements)

Medications

6 Assessment complete and correct, using appropriate terminology

5 Notation provides complete, concise picture of mother and baby (1 element)

1-4 Incomplete/inaccurate data, inappropriate terminology (2-6 elements)

0 Unsatisfactory/inaccurate data (more than 6 elements)

CARE PLAN GRADE: /25 POINTS

COMMENTS:

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:

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. Evaluate the role of the nurse in the ICN.

2. Identify the common procedures used in caring for the high risk neonate.

3. Assess the special needs of the premature infant, meconium aspiration infant, the infant suffering

from intrauterine or birth asphyxia, the drug dependent infant.

4. Participate in the care of a high risk infant (assessment, feeding, etc.)

5. 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

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.

05-23-2015

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

Prenatal care started @ weeks gestation

LMP: EDB:

G P (T P A L )

Maternal problems/risk factors with pregnancy:

Infants History

Birth Gender: male: _______ female: _____

Date of birth: 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: time:

SROM Clear

AROM Meconium

Course of current admission

Birth wt: Length:

FOC: Chest::

Growth %tile: Wt. gain/loss?

Diagnosis:

Pathophysiology (simple terms):

Family assessment (SES, family dynamics, language, etc.):

V/S @ T P R BP Pain

O2 Sats 8-hr I 8-hr O

Current assessment (refer to your computer documentation)

Neuro:

Cardio:

Respiratory:

GI:

GU:

Musculoskeletal:

Integumentary:

Diet:

Pertinent labs/diagnostics Pt Test Results

Normal Value

What do these results mean to you in caring for this baby?

05-23-2015

Medication Worksheet (all scheduled medications) Pts weight today: Medication, dose, frequency, route (if IV recommended dilution and rate)

Safe dosage range for patient

Drug type, why ordered Side effects

05-23-2015

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 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 one of which is assessment):

Rationale (1 for each intervention):

Outcomes Achieved/Not Achieved; Evaluation:

Changes/Additions needed:

#2 Second most significant neonatal and/or family problem

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 one of which is assessment):

Nursing Interventions (4, only one of which is assessment):

Outcomes Achieved/Not Achieved; Evaluation:

Changes/Additions needed:

05-23-2015

NICU Shift Report Student Nurse Name: _________________________ DOB GA at birth Corrected GA Gender

Diagnosis

Brief history

Assessment abnormals:

VS: T P R BP O2 Sat Pain

Diet Method

Intake PO NG IV

Output BM Type Void

Current weight Growth percentile

Supplemental O2 Method l/min

Meds scheduled PRN

Labs/x-rays

Plan/ interventions:

05-23-2015

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 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 Admission Data

3 Data is complete and correct, using appropriate terminology ( 1 element missing/incorrect) 2 Incomplete/inaccurate data, inappropriate terminology (2-4 elements) 1 Unsatisfactory/inaccurate data (5 or more elements)

0 Unsatisfactory/inaccurate data (7 or more elements) Neonatal Assessment

4 Assessment complete and correct, using appropriate terminology ( 1 element missing/incorrect) 3 Incomplete/inaccurate data, inappropriate terminology (2 elements) 2 Incomplete/inaccurate data, inappropriate terminology (3-4 elements) 1 Unsatisfactory/inaccurate data (5 or more elements) 0 Unsatisfactory/inaccurate data (7 or more elements)

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 Unsatisfactory/inaccurate data (5 or more elements) 0 Unsatisfactory/inaccurate data (7 or more elements)

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 Unsatisfactory/inaccurate data (7 or more elements)

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 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

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 Unsatisfactory/inaccurate data (7 or more elements)

CARE PLAN GRADE: /25 COMMENTS:

05-23-2015

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: