Nursing Process – OB Care Plan (RR 07/24/2020)
Student’s Name: _____________________________________
Course: PNP 125 _______
Date: ___/___/_______
Instructor: ___________________________
ASSESSMENT
I. Patient Information
Patient’s initial:
Age:
Marital status:
Occupation:
Culture/Ethnical background:
Religion:
Language spoken:
GTPAL__________________
When did prenatal care begin:
ETOH:
Allergies:
Recreational drug use:
EDD:
Delivery Date:
Maternal Blood Type_____ Rubella Titer_______STI status____________H/H__________________
Infant’s initials __________ Sex________Condition__________Weeks Gestation: ______________Breast or Formula feeding_______
Infant’s Blood type________ Other Bloodwork (i.e. Torch, accucheck, bilirubin) ________________
II. Assessment
History-Medical:
History- Surgical:
History- Psychosocial:
Nursing Diagnosis:
PNC: where was prenatal care provided?
Pregnancy: (brief description of current pregnancy)
Complications of pregnancy: (current)
Labor and delivery:
Labor onset:
Labor length: 1st stage
Type of delivery:
Pain medication:
Membrane status on time of admission:
Anesthesia:
Presentation:
Additional Notes:
Lab tests, ultrasound, amniocentesis, etc. results:
Nursing Diagnosis:
2nd stage
3rd stage
Fluid color:
Complications of delivery:
Type of delivery:
Parent-Infant interaction. Describe (mother/father, grandparents & sibling):
Physical assessment findings:
Vital signs: Pulse________Temp__________RR____________BP__________SpO2___________
Breasts:
Uterus:
Bladder:
Bowel:
Lochia:
Episiotomy/laceration:
Homan’s Sign:
Emotional status:
Abdomen (if C/s incision/dressing/bowel sounds
Lung sounds:
Heart sound:
Patient teaching needs:
Nursing Diagnosis:
MEDICATION SHEET
Medication
(Dose, Route, Frequency)
Nursing Diagnosis:
Classification
Diagnosis/Indication
Action of Drug
Nursing Concerns
(side effects, nurse
monitoring)
Medication
(Dose, Route, Frequency)
Nursing Diagnosis:
Classification
Diagnosis/Indication
Action of Drug
Nursing Concerns
(side effects, nurse
monitoring)
Nursing Diagnosis
(4 from NANDA list)
Nursing Diagnosis:
Goal (2 goals)
1 short term
1 long term
Nursing Interventions
(at least 5 nursing
interventions)
Nursing Rationale
(Reason for each
corresponding intervention
Evaluation/Recommendations
Nursing Diagnosis
(4 from NANDA list)
Nursing Diagnosis:
Goal (2 goals)
1 short term
1 long term
Nursing Interventions
(at least 5 nursing
interventions)
Nursing Rationale
(Reason for each
corresponding intervention
Evaluation/Recommendations
CLINICAL SKILLS EXPECTATION SUMMARY
Childbearing Family Nursing (OB)
Instructor Signature
Evaluation of labor Patterns
______________________________________________
C- section orientation
_______________________________________________
Fundal assessment
_______________________________________________
Newborn assessment
_______________________________________________
Ophthalmic medications
_______________________________________________
Feeding newborn- breast/formula _____________________________________________
Circumcision care
_______________________________________________
Bathing/diapering/cord care _______________________________________________
Communication/patient teaching ______________________________________________
Comments:
Nursing Diagnosis:
Date Observed
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
NORTH SHORE COLLEGE HOSPITAL
1400 S. Wolf Rd., Wheeling, Illinois 60090
Patient: DOROTHY GRANT
Room: 201
Sex: Female
Age: 25
MRN: 1868096
Physician: John Shelby, M.D.
Chief Complaint:
“My husband beat me and kicked me in the abdomen.”
History of Present Illness:
“He’s done this before, but this was the worst.” Multiple episodes of trauma inflicted by husband. Gonorrhea treated
successfully during last pregnancy. Rh negative – received Rho(D) Immune Globulin during each pregnancy. LMP – 30
weeks ago. G5 T3 P0 A1 L3 M0. She is at 30 weeks gestation, height – 5’4”; weight – 165 pounds. Vital signs: BP132/68; T-97.8; P-86; R-24; FHR-130s
Lab results on Wednesday 0245: WBC – 12.0; RBC – 3.48; Hemoglobin – 11.5; Hematocrit – 33; Platelets – 250,000;
Glucose – 90; Sodium – 134; Potassium – 4.2; Chloride – 105; Creatinine – 0.7; BUN – 10;
Medications: Prenatal vitamins.
Impression:
1. 30-week pregnant female with ecchymosis and abrasion on forearms and left lower abdomen consistent with report of
abdominal trauma imposed by husband.
2. Forearms bruised when she put arms up to protect her face and chest.
Plan:
1. Admit for observation and monitoring of fetal status.
2. R/O preterm labor.
3. Social services consult.
4. Psych consult.
5. Rho(D) Immune Globulin for Rh negative status.
PHYSICIAN’S ORDERS
Day/Time
Orders
Physician
Wed 1400
1. Terbutaline 0.25 mg subQ x 1 STAT. (telephone order)
2. Neonatal team consult.
Albert Seng, M.D.
Wed 1300
1. Anesthesia consult.
2. Terbutaline 0.25 mg subQ x 1 STAT.
1. Rho(D) Immune Globulin IM x 1 (1 vial – 300 mcg) for Rh negative
status.
2. Betamethasone 12 mg IM every 12 hours x 2 doses.
3. Fentanyl 50 mcg IV every 1 hour prn pain.
4. Advance diet as tolerated.
5. Prenatal vitamin 1 PO daily.
Albert Seng, M.D.
1. Admit to Labor and Delivery.
2. Vital signs every 4 hours.
3. Bedrest with BRP.
4. NPO
5. Record Intake and Output.
6. Continuous EFM.
7. OB ultrasound done in ED.
8. Labs done in ED.
9. IV of Lactated Ringer’s at 125 mL/hr when bolus completed.
John Shelby, M.D.
Wed 0730
Wed 0345
Albert Seng, M.D.
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NORTH SHORE COLLEGE HOSPITAL
1400 S. Wolf Rd., Wheeling, Illinois 60090
Patient: DOROTHY GRANT
Room: 201
Sex: Female
Age: 25
MRN: 1868096
10. Social work and Psychiatric team consults.
Wed 0200
Physician: John Shelby, M.D.
1. IV bolus of 500 mL Lactated Ringer’s, then at 250 mL/hr.
2. Labs: STAT: CBC and coagulation studies, chem 7, urinalysis, type
and screen.
3. OB ultrasound.
4. Notify OB for further orders/management.
Melvin Carruthers, M.D.
PHYSICIAN’S PROGRESS NOTES
Day/Time
Notes
Wed 1700
SVE 6/90%/0. Membranes ruptured during exam with light meconium
staining. FHR 130s, moderate variability. Contractions continuing.
Anticipate preterm birth. NICU consult done.
Neonatal consult completed/dictated.
Contractions and vaginal bleeding increasing; lungs clear. Terbutaline
ordered. Anesthesia to see patient.
25-year-old Caucasian female, G5, P3, A1, 30 weeks gestation, seen in ED
for blunt abdominal trauma secondary to husband hitting and kicking
abdomen of patient. Fundal height 29 cm. Ecchymosis and abrasions
apparent on left lower abdomen and forearms. Remainder of physical
examination WNL. OB ultrasound revealed normal fundal placement of
placenta with no evidence of abruption. Fetus active with FHR in 130s.
Admitted for observation. Mild contractions started approximately 2 hours
after admission.
Wed 1545
Wed 1300
Wed 0730
Signature
Albert Seng, M.D.
James Smith, M.D.
Albert Seng, M.D.
Albert Seng, M.D.
Plan:
1. IV LR 500 mL bolus, then at 125 mL/hr.
2. Tocolysis if contractions continue.
3. Social services and Psychiatric consult.
4. Rho(D) Immune globulin for O negative blood type (patient missed her
28-week appointment and did not receive the Rho(D) Immune globulin at
that time).
5. Betamethasone now and again in 12 hours if not delivered.
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