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SCHOOL OF NURSING
OB CLINICAL WORKSHEET: NURSING PROCESS CARE PLAN: INTRAPARTUM
Temperature
Pulse
Respirations
Vital Signs
PressureBlood
Dilatation
Effacement
Station
Vaginal Exam
Membranes **
Mem. Fluid **
Base L:ine
STV
LTV **
PC **
Fetal Monitoring
Method **
Frequency
Duration
Method **
Uterine Activity
Quality **
Intensity 0-10
Pain
Med\Epidural
Maternal Pos. **
Pt Care Interv **
Status
LOC
Long Term Variability (LTV) Quality Peak/Resting Maternal Position
ABS= Absent 0-2BPM External/Palpation T= Trendelenberg
MIN= Minimal 3-5 BPM 1+= Mild L= Lithotomy
MOD= Moderate 6-25bpm 2+= Moderate C= Chair
MK- Marked >25BPM 3+= Firm LL= Left Lateral
S= Soft RL= Right lateral
SQ= Squatting
Periodic Changes (PC) LF= Low Fowlers
A= Acceleration FHR 15 BPM above HF= High Fowlers
baseline X 15 sec BR= Bedrest
VD= Variable Deceleration Membranes (Mem) AMB= Ambulating
LD= Late Deceleration I= Intact
ED= Early Deceleration R=Ruptured
PD= Prolonged Deceleratio B=Bulging
S= Sinusoidal S=SROM Interventions (Pt Care)
A=AROM OC= Oral Care
PC= Peri Care
Fetal Monitoring Method LC= Linen Change
A= Auscultation WP= Warm Pack
D= Doppler Membrane Fluid CP= Cold Pack
E= External FM C= Clear F= Foley
I= Internal, Electrode M= Meconium Stained M= Massage
Bi= Bloody
F= Foul Smelling
Level of Consciousness (LOC)
Aw= Awake
A= Alert
Uterine contractions method S= Asleep
P= Palpation C= Confused
E= External, TOCO D= Drowsy
I= Internal, IUPC Sc= Semi comatose
M.Rogers-Walker
Updated 10/08
MEDICATIONS/TREATMENTS
Name Classification Major Actions Dose/Route Adverse Effects Precautions
(trade/generic) (why client taking Safe range Contraindications
this drug) Nursing Implications
Student Name:_____________________________________
M.Rogers-Walker
Updated 10/08
Pertinent Laboratory Data Prenatal Labs Pertinent Laboratory Data Pertinent Laboratory Data
Hgb/Hct #1_______________ RPR: Nonreactive or Reactive Lab Test #1_______________ Lab Test #2_______________
Hgb/Hct #2______________ GBS: Negative or Positive _________________________ _________________________
_________________________ TX: _____________________ Results___________________ Results____________________
Rubella Immune/Non immune _________________________ _________________________
Hep B: Negative or Positive _________________________ _________________________
HIV: Negative or Positive
Rationale for abnormal results Rationale for abnormal results Rationale for abnormal results Rationale for abnormal results
_________________________ _________________________ _________________________ _________________________
_________________________ _________________________ _________________________ _________________________
_________________________ _________________________ _________________________ _________________________
_________________________ _________________________ _________________________ _________________________
_________________________ _________________________ _________________________ _________________________
M.Rogers-Walker
Updated 10/08
Assessment Data Nursing Expected Outcome Nursing Rational for Evaluation of goals
Subjective/Objective Diagnosis Short/Long term Interventions interventions
M.Rogers-Walker
Updated 10/08
Assessment Data Nursing Expected Outcome Nursing Rational for Evaluation
Subjective/Objective Diagnosis Short/Long term Interventions interventions
M.Rogers-Walker
Updated 10/08
Date:_____________ Documentation Sheet
Time: __________________
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M.Rogers-Walker
Updated 10/08