Chief Complaint Contractions, rupture of membrane or bleeding
Contractions, rupture of membrane or bleeding.
NSVD, or C-Section
Admitting Dx (Cite References) Medical, Surgical, Social History and OB History
Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14)
Medical Management/ Orders/ Medications & Allergies (2)
Erickson’s Developmental Stage Related to pt. & Cite References (1)
Patient Education (In Pt.) & Discharge Planning (home needs )
Diagnostic Test/ Lab Results with dates and Normal Ranges (3)
Priority nursing diagnosis #2
Vital Signs (4)
Interventions # 2
Assessment/ Evaluation #1
Assessment/ Evaluation #2
PC Evaluation Plan
Potential Complications/ at risk for
Rest/ Exercise (11)
Priority nursing diagnosis #1
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