Chief Complaint Contractions, rupture of membrane or bleeding

Chief Complaint

Contractions, rupture of membrane or bleeding.

 

 

 

 

Admitting Diagnosis

NSVD, or C-Section

Medical Conditions

Patient Information

(1)

Name:

 

Age:

 

Height/Weight:

 

Allergies:

 

Gestational Age:

 

Admitting Dx (Cite References) Medical, Surgical, Social History and OB History

 

 

 

 

Medical History

 

 

 

 

Surgical History

 

 

 

 

Social History

 

 

 

Obstetric History

GTPAL

Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14)

 

 

 

 

Medical Management/ Orders/ Medications & Allergies (2)

 

Name

Dose

RT

Freq.

MOA

RN Considerations

Onset/Peak/Duration

(Insulin)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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)

 

 

Test

Norms

Date

 

Current Value

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Concept Map

Student Name:

Instructor:

 

 

 

 

 

 

PC Outcomes/Goal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Priority nursing diagnosis #2

 

 

Respiratory (7)

 

Vital Signs (4)

 

Integumentary (12)

 

 

Interventions # 2

 

Assessment/ Evaluation #1

 

Assessment/ Evaluation #2

 

 

PC Evaluation Plan

 

Potential Complications/ at risk for

 

PC Interventions

 

Psychosocial (14)

 

Cardiovascular (6)

 

 

Endocrine (13)

 

Misc. (Ht/Wt)

 

GU (10)

 

GI (9)

 

Nutrition/Hydration

(8)

 

Rest/ Exercise (11)

 

Neurological (5)

 

Outcome/Goal #1

 

Priority nursing diagnosis #1

 

 

 

 

 

 

 

 

 

 

 

 

 

Outcome/Goal #2

 

 

 

 

 

 

 

 

 

Interventions #1