MIAMI DADE COLLEGE

SCHOOL OF NURSING
OB CLINICAL WORKSHEET: NURSING PROCESS CARE PLAN: INTRAPARTUM

STUDENT NAME: _________________________________________________________________ DATE: ___________________

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Client Initials:_______________________ Culture/Ethnicity ____________________ Support System ________________________
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Age:_________ Room/Bed__________
Religion ___________________________ _____________________________________
Gestational Age:_____________________
Language __________________________ Time/Date of delivery: __________________
Weight:___________ Height:__________
G___ T____ P____ A ____ L ____ Marital Status ______________________ Type of Delivery:
Vaginal _____Cesarean**_____
Estimated Due Date:_________________ Occupation _________________________ Forceps_____ Vacuum _______
** Give reason for Cesarean delivery:
Admission Date:___________________ Health Insurance ____________________ ____________________________________

Physicians Name:____________________ Current Work Status _________________ ______________________________________

Blood Type: ________________________ Highest Grade Level Completed EBL (estimated blood loss):_______________
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RhoGam: Yes or No Time/Date:___________ Prenatal Records: Yes or No Allergy:_______________________________
Brief Health History: ______________________________________________________________________________________________________
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Assessment: _____________________________________________________________________________________________________________
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 Date/Time

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
Hgb/Hct #1_______________
Hgb/Hct #2______________
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Rationale for abnormal results
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Prenatal Labs
RPR: Nonreactive or Reactive
GBS: Negative or Positive
TX: _____________________
Rubella Immune/Non immune
Hep B: Negative or Positive
HIV: Negative or Positive
Rationale for abnormal results
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Pertinent Laboratory Data
Lab Test #1_______________
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Results___________________
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Rationale for abnormal results
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Pertinent Laboratory Data
Lab Test #2_______________
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Results____________________
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Rationale for abnormal results
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INTRAVENOUS SOLUTION #1 INTRAVENOUS SOLUTION #2

Type: _________________________________________________ Type: ________________________________________________________
Cc/hr: _________________________________________________ Cc/hr: ________________________________________________________
gtts/min: _______________________________________________ gtts/min: ______________________________________________________
Additives: ______________________________________________ Additives: _____________________________________________________
Rational for solution: ____________________________________ Rational for solution: ___________________________________________
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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: __________________
Nurses Note:_____________________________________________________________________________________________________________
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Time: __________________
Nurses Note:_____________________________________________________________________________________________________________
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M.Rogers-Walker
Updated 10/08