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Bon Secours Memorial College of Nursing- N4111-P

Clinical Paperwork Grading Rubric


Labor & Delivery
Student Name: Allegrah Nguyen
Section

Points
Allowed

Initial Nursing Report

Labs

This Shift Section

Fetal Heart Rate Tracing/Uterine


Activity

13

Safety Actions

Orders/Nursing Interventions

Culture

Nursing Diagnosis

Goals/Outcomes

Nursing Interventions

Rationale

12

Evaluation

Medications

Class/Clinical Concepts

Total Grade

100

Points Earned

Bon Secours Memorial College of Nursing - NUR 4111P


Labor and Delivery Writing Assignment
Students Name: Allegrah Nguyen
Patients Initials: T.R Age: 23 y.o

Date: 09/23/2015
MD/CNM: Campbell

Initial Nursing Report:


G2TP1AL
EDD: 09/30/2015
Weeks: 39w1d
Blood type & RH:O+ RhoGAM? No
Induction? Yes Type of induction (method) Pitocin
Augmentation? No
Time oxytocin (Pitocin) started: 0750 Current Pitocin rate in mu/min: 2mu/hr
Anticipated Pain Management Pt elects to withhold pain medication at this time, however
epidural was discussed
Pain medications given? None Medication/dose/time/route
IV: Site Right arm Fluid ordered Rate125 ml/hr of NS
Bolus given? No If so, why, when, and how much?
Medications Given Last Shift None
Last Void 0719
Foley No
Breast/Bottle Feeding (any restrictions?) Pt plans to breastfeed.
Any prenatal complications or problems? Vaginal bleeding r/t poss domestic abuse. Pt signed out
AMA on 09/18/2015. Hx of abuse by partner, baby result of rape, concern for care d/t poor social
status.
Any relevant medical problems? Colpectomy in 2013
Type of delivery anticipated: Vaginal Delivery
Vital Signs: Temp 98

Resp 16 BP 106/56 HR 75

Labs: HepBsAg Neg


HIV Neg
Rubella Neg
HPV Neg
GC/CT Neg
RPR/VDRL/STS Neg
Herpes/HSV Neg
GBS +
Last cervical exam: Time 0757
Dilation 3
Effacement 50%
Station -2
Cervical Consistency Medium

Cervical Position Posterior


Bishop Score 6 (use attached tool)
Membranes
ROM: Type AROM Time0757
Fluid amt/color Clear, moderate
This Shift:
Vital Signs: Temp 97.9 Resp16 BP122/73 HR 72
Intake None since being admitted
Output 1 urine occurrence
Pain Management: None- patient states she is not in pain
Medications given and why:
FHR Tracing
External or FSE? External
Avg Baseline135
Baseline Variabililty 6-25 bpm
Decels Present? No Type: n/a
Interventions Done: n/a

Accels Present Yes

Uterine Activity
External or IUPC? External If IUPC, why placed? n/a
Frequency:3-4 Duration: 60-80 sec Intensity:Mild
Did patient deliver? Not during shift What type of delivery? n/a
If cesarean section, why?n/a
List 2 patient-specific safety actions implemented during your shift:
1. Patients was no info which meant that none of her identifiers were displayed for others to
see it (whiteboard, etc). For her safety, her identify was under strict protection because she did
not want the father of the baby to know where she was. He had been known to threaten her and
the baby.
2. Verify allergies and identification bracelet on patient and make sure the patient had an allergy
bracelet on.
List 3 orders that are specific to and appropriate for your patient.
1. Penicillin order d/t patient being GBS+.
2. Checks every 30 minutes after the start of Pitocin to check the pt status, and FHR status.
3. Education on pain management, specifically in regards to possibly receiving an epidural.
List 3 nursing interventions performed during your shift. (Do not repeat the same
interventions you use in your care plan).

1. Assisted with comfort measures (ie: back/leg rubs and applying sacral pressure) to promote
relaxation and well-being during contractions.
2.Assessed degree of discomfort through verbal and non-verbal cues.
3. Encouraged patient to void every 1-2 hours.
Culture:
Compete and attach Cultural Assessment Tool
Nursing Care Plan
Nursing Diagnosis
Select one problem area and develop your three-part nursing diagnosis. Use your nursing care
plan textbook to assist you to write the three part nursing diagnosis statement (nursing diagnosis
r/t etiology aeb data) Remember, risk for nursing diagnosis do not have aeb data.
Dx Risk for ineffective coping
aeb situation crises
Planning must reflect nursing diagnosis
List one goal and two outcomes that you would like your patient to achieve. (The patient
will) Outcomes should be behavioral, measurable, realistic, and include a time frame
during which you cared for the patient.
Goal Patient will demonstrate effective coping by 1330 hrs (end of shift).
Outcome 1) Patient will identify effective coping behavior by 1330 hrs (end of shift).
Outcome 2) Patient and support system will engage in activities to maintain and enhance
control by 1330 hrs (end of shift).

Nursing Interventions
List four nursing interventions for the diagnosis you selected. (The nurse will)

Cite rationale in APA format. Use your textbook or a nursing care plan reference. Remember
that each outcome must be supported by at least one obstetrical nursing intervention with an
obstetrical rationale.
1) The nurse will ascertain patients understanding and expectations of the labor process.
Rationale: The patients coping skills are most vulnerable during labor, specifically as the
contractions become more intense. Lack of knowledge, misconceptions, or unrealistic
expectations can have a negative impact on coping abilities (Doenges, Moorhouse, & Murr,
2011).
2) The nurse will encourage verbalization of feels.
Rationale: Helps nurse gain insight into individual needs, and assists patient to deal with concern
(Doenges, et.al, 2011).
3) The nurse will reinforce use of positive coping mechanisms and relaxation techniques.
Rationale: Assist patient in maintaining or regaining control. Enhance feelings of competence,
and self-esteem. The stressors of labor can threaten the womens self-esteem, especially if she
has not coped positively with past experiences and/or successfully accomplished the task of
pregnancy (Doenges, et.al, 2011).
4)Demonstrate behaviors and techniques support system can use to assist with pain control
and relaxation. Provide information regarding, water, music, imagery, aromatherapy and
correct misconceptions.
Rationale: Encourages choice of multiple options, enhances coping and self-esteem of patient
and her support group (Doenges, et.al, 2011).
Evaluation-Goal and outcomes met/partial met or not met? Include rationale for your answer.
1) Goal: Met, patient was able to effectively demonstrate effective coping by 1330 hrs.
2) Outcome 1: Patient was able to identify coping behaviors through verbalization of feelings,
and gaining an understanding of the laboring process by 1330 hrs.
3) Outcome 2: Patient and her support system were able to correctly verbalize and demonstrate
activities they could do to help patient maintain control during the laboring process by 1330 hrs.

Medications:
Reference your text book and drug guide to provide information for all of the following
medications (even if your patient did not receive these medications).
**Include obstetrical action, dose, route, frequency, action, side effects (maternal and fetal), and
obstetrical indications for use.
1. Cervidil (Dinoprostone)
Actions: Softens the cervix and facilitates cervical dilation and effacement.

Indications: Patients at or near term that need assistance facilitating induction of labor.
Route: Vaginal insert
Dosage: Insert at 10 mg, released 0.3 mg/hour over a 12 hour period that needs to be taken out
when labor is active.
Side Effects:
Mother: Diarrhea, vomiting, nausea, backache, headache, fever, irregular uterine contractions,
shivering, vaginospasms, myocardial infarction
Fetus: Abnormal fetal heart rate, fetal heart deceleration, late fetal heart deceleration, fetal
distress
2. Pitocin (oxytocin)
Actions: Stimulates contractions of uterine smooth muscle by increasing intracellular calcium
contractions thus mimicking contractions of spontaneous labor.
Indications: Induction of labor, postpartum hemorrhage, termination of pregnancy
Route: Inj, IV, nasal
Dose: Initial 0.5-1 mu/min IV, gradually increase in increments of 1-2 mu/min every 30-60
minutes until desired contraction pattern has been established. Once contractions have been
reached and labor has progressed to 5-6 cm dilation, the dose may be reduced by similar
increments
Side Effects:
Mother: nausea, vomiting, hypertensive episode, ventricular premature beats, afibrinogenemia,
subarachnoid hemorrhage, postpartum hemorrhage, brain damage, coma, CNS defect,
convulsions in newborn, pelvic hematoma, rupture of uterus and death
Infant: cardiac dysrhythmia, fetal bradycardia, ventricular premature beats, retinal hemorrhage,
low Apgar score at 5 minutes

3. Cytotec (Misoprostol)
Actions: Induction of labor and cervical ripening (d/t prostaglandins), can also be used for
NSAID induced gastric ulcer and termination of pregnancy in combination of mifepristone.
Indications: Induction of labor
Route: oral, vaginally
Dose: Cervical ripening: 25mcg vaginally (gel) every 3-4 hours (max dose, 400 mcg) or 200 mcg
vaginally for 24 hours or until active labor
Induction of labor: initial, 50 mcg orally every 4 hours for 2 doses, then 100 mcg every 4 hours
until membrane ruptures (max 5 doses)
Side Effects:
Mother: abdominal pain, diarrhea, cardiac dysrhythmia, chest pain, myocardial infarction, GI
hemorrhage, anemia, thromboembolic disorder, test allergic shock, deafness symptom, rupture of
uterus, TSS
What concepts learned in class did you put into practice today?
The concepts I learned were specifically learned during the comfort measure class that was taken
at St.Marys. I established a positive relationship with my patient early on, so she really trusted

and respected what I had to say about the laboring process. Her family intently listened to some
of the pain management techniques that I learned, to alleviate some discomfort. I even made
them a copy of the pamphlet that I was provided so that they could refer back to it, at the end of
my shift.
One concept I put into practice from class was family dynamics. My patients family was not
your traditional nuclear family, but more of an extended family dynamic. It was great to see them
interact and work together towards making the patient more comfortable and relaxed during her
last couple of hours of pregnancy.

Pledge: I have neither given nor received aid, other than acknowledged, on this assignment,
nor have I seen anyone else do so.
Signed: Allegrah Nguyen

Cultural Assessment Tool

Bon Secours Memorial College of Nursing


NUR 4111P
Can you read and/or write English? Yes
Support/Family

Nutrition

Who is your support system?


Mother, aunt and daughter.
Who should not enter your room?
Husband and father of daughter.
Who makes decisions within your family?
We do it collectively.
Who makes decisions regarding your healthcare?
I do.

Preferred temperature of food:


Hot
Ice in water pitcher or mug?
Neither, prefers it room temperature
Food preferences:
Not picky.
Prohibited foods:
Onions
Will someone bring you food from home?

Not home cooked food, but probably take out.

What family members are staying with you at the


hospital?
Possibly mother and daughter.
Level of family involvement observed:
Extended family, that were very boisterous about the
new baby.

Infant Care

Infant Feeding

What customs affect the care of your newborn?


(examples: no praise to newborn, particular clothing,
naming at later date, etc.)
Patient would like to wait 3-5 minutes before cutting
the cord, because she said that they baby will receive
one last push of her blood.
Will your newborn be rooming in?
Yes

Breast or bottle feeding?


Breast
If breastfeeding, is colostrum OK?
Yes
Will you be pumping?
Yes
Are pacifiers OK?
She is open to it, but would prefer not to use it because
she heard that it can cause nipple confusion.

Do you want your newborn circumcised?


n/a

Will staff or your family assist you in feeding?


No.

If yes, what rituals or special practices will be


followed?
n/a

Other Information/Comments
What healthcare/folk medicine practices will you/do you follow related to after birth or newborn care?

No
What religious or spiritual beliefs or customs can we help you with during your stay?
No
Is there any care we provide that differs from your customs/beliefs? If so, describe in detail.
No
Who will help you and your newborn while you are here and at home?
Patients Mother
Adapted from: Cooper, M., Grywalski, M., Lamp, J., Newhouse, L., & Studlien, R. (2007). Enhancing cultural
competence: A model for nurses. Nursing for Womens Health, 11, 148-159.

Bishop Score
Dilation

0
0 cm

1
1-2 cm

Effacem 0-30% 40-50%


ent
Station -3
-2

2
3-4
cm
6070%
-1/0

3
5-6
cm
80%
or >
+1/+
2
--

Consiste Firm
Medium Soft
ncy
Position Poster Midposit Anteri -ior
ion
or
Total
score

Score
2
1
2
1
0
6

Reference
Doenges, M., Moorhouse, M., & Murr, A. (2011). Nursing care plans guidelines for
individualizing patient care across the life span (8th ed.) [CD ROM]. Philadelphia: F.A.
Davis.