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: