Marian University School of Nursing NUB 330 Maternity Nursing Labor and Delivery Assessment and Care Plan (Need to turn in 2 complete Assessments/Care Plans, but must fll out an assessment — the first part - in all LD patients) > Student. Daniel eed Date of Care in \o Patient Information: Patient’s initials eT Marital Status Race Occupation. \ 0 Reason for Admin MME ttergies_ NK Support Person(s) Present SENG, WOVE. Significant Past Pregnancies/Medical/Surgical History Quo NOG Current Pregnaney G2 12 PO adr] top OA [Joy EDC (due date)? lls Boa 4O BFW ghyou) Prenatal care:Q)N Childbirth education: @N Birth plan: YQ) Weight gain Current Medications Rownertl Vito Significant current pregnancy factor/risks i Preterm labor No __ Gestational Hypertension _~ Ng Diabetes type Bleeding Previous PP Mood Disorders_No Alcohol use Smoking Wy _Drug use Prenatal labs: ABO Rh_~__ Glucose Tolerance Test Nova GBBS: -/+/@aB Rubella: Immune /Non-immune /GD HepB Q/+/unk RPR/VDRLO/+ junk HIVO/+/unk Date: Zé {| Heb 10,4 Het 3.8 —/pate:_ NA Heb NA cr NALabor Assessment Date/Time: Onset of labor QlyfX) Fetal Presentation: Cephalie/Breeeh/Face/Shoulder Fetal Postion: Wainy, Status of membranes (circle): EROMVAROM Date/Time) (SROM=spontaneous rupture oFmembranes; AROM-artificial rupture of membranes) Color: clear@GeconiuD/bloody/pink-tinged/purulent Anich Odor: nonef{oul) Amount: small/moderate(arg’ Last oral intake Date/Time _((yQD. Any current complications Mconiun) ¥y Membrane Nicw cake) / Current labs: Hab |0.A) Het 4LR platelets Blood Glucose MA OT. fit LFTs: ALT. AST_ AJ LDH_(Uf SG RFTs: BUN WW | Uric Acid Creatinine WA Urine Protein WA Aw Range of Vital signs during labor: ae tay L4 THB pO-72._ R-|,, Stage] Length (onset of labor through 10 ems dilation): lyr) Complete the FHR monitoring assessment data sheet every half hour during your clinical day while your patient is in labor. Vaginal exams: Upon report: Time Fffacement 40%, Dilation (p@| —_station_~3 Position \ky he Bleedin; Changes throughout the day: Time. ee Dilation_4CM_ Station ~ 4 Position Vortex Bleeding Time, Effacement_[| Dilation (Op) station + | Position Vertey, a) Bleedin;Time Effacement Dilation Station Position Bleeding Pain assessment Initial assessment: Time Pain Score (scale 0-10) Describe ae Intervention, Pain relieved? Y/ thanges throughout the day: Time 090) Pain Score 1 (scale 0-10) Describe Intervention, Pain relieved? Pain Score Q (scale 0-10) Time Describe Intervention, Pain relieved? Patient's emotional status throughout labor (YY MO. aligned elated ; : Support person(s)’ partcption ary 2 LOU GUNNA Procedures done in Stage I (circle): 1& O cath(Fgl@YIUPC placed/FSE placed/ ]Other-explain Summary of events in Stage I — Describe changes from Early/latent phase, to active phase, to transition and any significant events.Stage H Length (10 cms dilation through birth of baby): ana Owls Time: 10cm|\'fguaTime pushing began: |L}24__ Time of detivery: \\'\U Type: Vaginal>Gpontaneous)Forceps/Vacuum If Cesarean Reason, Episiotomy/Lacerations: 1* degree, 2" degree, 3" degree, 4" degree (circle) Noy Complications during Stage II Maternal ne Support Person(s)’ Reactions Summary of events Stage 1 thal Kater Stage III Length (Birth of Baby to Birth of Placenta): yar, Qitocin\eytotec/hemobate/methergine/other: Total EBL (estimated blood loss) ¢ ) 0 Complications_[\V asec Initial Maternal response. felt Ye Maternal Comfort/Pain Assessment: Diy we Your Response to the delivery of the infant and the placenta! Aomb wan, fehcome WrGaure dung Qeatin onto we Mowe Row) odo Placenta Tim Medications(circle):Stage IV: Initial postpartum assessments ‘At delivery vs: BPO _P_GO RU TH Uterine Assessment Fundus level: -3,-2,-1,@,+1, +2, 43 Position: midline, right, left Consistency: _firm, boggy, firms with massage Lochia amount: — scan/moderate/large/clots Color: rubra/alba/serosa Bladder: palpable/non-palpable 15 minutes Time: (LH Fundus level: Position: midline, right, left Consistency: firm, bogey, firms with massage Lochia amount: — scant/moderate/large/clots Color: rubra/alba/serosa | Bladder: palpable/non-palpable 30 minutes VS: BP TAT PAT RI | Time: 1 x Uterine Assessment Funduslevel:—-3, -2,-1,@, +1, +2,43 | Position: midline, right, left Consistency: firm, bogey, firms with massage Lochia amount: _ scant/moderate/large/clots | Color: rubra/alba/serosa | Bladder: palpable/non-palpable minutes | VS:BP_N_PI NE Time: be Uterine Assessment Fundus level: -3,-2, -1,@_+1, #2, 43 Position: midline, right, left Consistency: firm, boggy, firms with massage Lochia amount: “scant/moderate/large/clots, Color: subxa/alba/serosa Bladder: palpable/non-palpable Sminuies | VS:BP_NA PNA NEF z Time: 10 | Uterine Assessment .L@,+1.+ Fundus level: -3, idling right, left Consistency: iim, boggy, firms with massage Lochia amount: “Scant/moderate/large/slats Color: pubra/alba/serosa Bladder: palpable/non-palpableDescribe bonding/attachment bshviosBresedine ONSHCD, WAN OU 9 oO Akin Mae Aw hotel Infant: APGARSCORE —— Imin. 8 Smin, 9 Sign [Score 0 score 1 Score 2 ‘Acronym Color Pale/Blue Iue Extremitigs | Completely Pink | Appearance Heart Rate ‘Absent <100;mi TO0/mi Pulse [Reflex Irritability | No response to | Grimace/feeble | Cough/Sneeze stimulation Cry when | stimulated | Muscle Tone Flaceid Some Flexion Activity Breathing/Respiration | Absent | Weak, irregular » | Respi sex F_ weight (glheSmength (9.4 orc SYgycord vessels: Significant findings on Head to Toe Assesment (yuna. i.) Feet Circle One: SGA/LGA Istset of vs: T 44.4 p\44 Re 4Q and set of WIS: TGF PAY RAG 3rd set orws: TRO pyr r Yor ‘Accucheck vcr NA : Medications Given: QitB)/ Hep B/ Erythromycin Opihalmid) Other? Feeding Type/Amount, NI Voids ___ Stools let Bath? YR) 4" set of W/: 1 RSA pie a Transfer Note: (With MothgYNICU/SCN__Cultural Assessment (Culture refers to norms and practices of a particular group that are learned and shared and guide thinking, decisions, and actions. Cultural values the individual's desirable or preferred way of acting or knowing something that is sustained over a period of time and which governs actions or decisions Taken from hitp://www.culturediversity.org/basic.htm.) Assessment of Developmental Level (Erickson-Determine the work stage/action stage your patient is exhibiting most. Provide evidence of why you came to this conclusion, Example: isolation vs intimacy is the Erickson’s level of development. She has more tendencies toward intimacy because she exhibits the following behaviors; touching, holding, cradling, breastfeeding, eye contact and verbal co] munication with her infant.) 0) 0. 2 a Ti claNiol. MN Spiritual Assessment (Questions that may help you with this assessment are: What is strength for you? Where can you get it? Who gives it to you? How can you get more? ‘What is peace for you? Where can you get it? Who gives it to you? How can you get more? What is security for you? Where can you get it? Who gives it to you? How can you get more? 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APT | vant wee 7,b0 VN \waynahong ~franpidy SA IG Layo 1 FARR PAN BN] Ky 0 OD NANNY THA, WKAR 0 YORE Wk CHPFAKI 00 uoyay Jo wstTEyDayy asesog | suonEoIpayy (spa [eanpidg pue spmy AL apnpur esvojd) [eUIo eA, PARED OL OPO, 0 RYH I Fata 900) BL AD eat 5 Paani ahi Wr eat aU “RY, UO, 9st a ‘Kaan ant i ON HA _sosoudeyp anos yaoldns yuyp SoBe p juaUtissasse Woay BIE JUDH LM puvdtytUa|s [Je azjawUtT epg avg, id amp uy quSelf-Grading Criteria: (All assessments/care plans must demonstrate mastery) Content All Assessment completed All References and page #s are provided Logical Flow Priority Order Nursing Diagnoses are supported by assessment and are NANDA approved Goals/Outcomes Realistic Timed Measurable Interventions Specific and Individualized Scientific Rationale documented Thorough At least 3 interventions for each category: Diagnostic ‘Therapeutic Educational Presentation Grammar ‘Typed Submitted on time References used: AP AF PAR FOF PPSelf-Reflection Describe how you incorporate Dignity of the Individual "Y_ \w edueld Ne due ea sg Las ea he St o ay Peace and Justice your care the Franciscan Values: Responsible Stewardship Reconciliation SF toroid Ay gare Avo Se OR etins, “Lerid ets Katey where. Describe the areas which you need to strengthen in providing nursing care: Understanding Ang, FR paar ave) aaa Fea WoriAov tn, Senet 1 NORTE Reflect about three different events today that triggered emotional reactions today. Reflect and write about these feelings: Legkeationds wen T cat Wey on. IN irene » The toy, ho “te a AS WX ony gta Ov weil o Mat: Instructor Feedback: