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)
Assessment
Assessment Data
Subjective/Objective
Nursing Diagnosis
Plan
Outcome Criteria
(Client Centered)
Interventions
(Nurse Centered)
Rationale for Interventions
(REFERENCED)
Assessment
