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Posted: September 4th, 2023

CLINICAL WORKSHEET: MATERNITY NURSING PROCESS CARE PLAN

ASSOCIATE SCIENCE IN NURSING

CLINICAL WORKSHEET: MATERNITY NURSING PROCESS CARE PLAN

STUDENT NAME

DATE

Client Initials

Culture/Ethnicity

Support System

Unit

Room/Bed

Religion

Age

Sex

Language

Pre-preg Wt

Pre-preg Ht

Marital Status

Children & Ages

Current Wt

Current Ht

Occupation

G

T

P

A

L

Health Insurance

Current Work Status

Current Medical Diagnosis

Name of Significant Other/Primary Caregiver

Highest Grade Completed

Pain

Rating, Quality & Location

Infant Feeding

Date/Time of Delivery

Delivery Type (Vaginal, Cesarean**, Forceps, Vacuum)

**Reason for Cesarean

Diagnostic procedures

Surgical procedures

Pathophysiology/Psychopathology (List Reference)

Reference

Today’s Assessment

M

Admissions Vital Signs

A

T

Frequency

B

P

U

R

BB

B/P

L

Allergies/Side Effects

E

H

Brief Health History

Diet with Rationale

Time

Flowsheet Notes

Activity Order

Limitations/Prosthetic Device

PERTINENT LABORATORY DATA

Lab Test # 1

Lab Test # 2

Lab Test # 3

Lab Test # 4

Hgb/Hct #1

Hgb/Hct #2

Results

Results

Results

Hgb/Hct #3

.

Rationale for abnormal results

Rationale for abnormal results

Rationale for abnormal results

Rationale for abnormal results

.

INTRAVENOUS SOLUTION #1

INTRAVENOUS SOLUTION #2

Type

Lactate Ringers’ (main IV)

Type

500 ml NS (piggyback)

cc/hr

125

gtts/min

cc/hr

gtts/min

2 milliunits/minute via pump

Additives

Additives

30 U Oxytocin

Rationale for solution

Rationale for solution

.

Medication Name

Generic/Trade

Classification

Major Actions

(why taking meds)

Dose/ Route

Safe Range

Adverse Effects

Nursing Implications

Assessment Data

Subjective/Objective

Nursing Diagnosis

Plan

Outcome Criteria

(Client Centered)

Interventions

(Nurse Centered)

Rationale for Interventions

(REFERENCED)

Evaluation

Assessment Data

Subjective/Objective

Nursing Diagnosis

Plan

Outcome Criteria

(Client Centered)

Interventions

(Nurse Centered)

Rationale for Interventions

(REFERENCED)

Evaluation

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