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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
(
2
)
.
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
Have you received a push notification like this?
Real Message: I just want your $$$
@DrWendyGuess
Hi John. Your order should be arriving on Thursday. Would
you like to set up a date & time to install it? Just reply with
your preferences. Wendy
Real Message: You care about the customer)
Or …. Has a note like this one
arrived just at the perfect moment?
@DrWendyGuess
Which Would YOU Rather Read?
Welcome. Wondering about the MyTalk.Rocks?
Link -
http://mytalk.rocks
Rock The Speaker
Send A Photo
Share Feedback
Ask Questions?
@DrWendyGuess
What’s better for your LTV/ROI?
@DrWendyGuess
How would it be for your clients
to feel like you’re a mind reader?
@DrWendyGuess
@DrWendyGuess
Part 1: Design Campaign
What am I really delivering?
My guiding principles
Beyond the product…
For Support
To build Community
Improve Productivity
Create Distraction
Or adding to Frustration
DESIGN CAMPAIGN
@DrWendyGuess
Part 2: Customer Journey
How do they really feel about it?
Are they a hunter or gatherer?
Which CTA did they follow?
What do they expect to find?
What stage are they in? (CRM)
What UX concepts are added?
CUSTOMER JOURNEY
@DrWendyGuess
Part 3: Questions/Concerns
What do they really need to know about Product/Service?
Logistical details
A surprise feature
How they’ll feel using it
Other ways to use product
Industry/Insider tips
QUESTIONS /CONCERNS
@DrWendyGuess
Part 4: Response Timing
When do they need to know it?
At first glance
Deep dive
After hesitation
Leading up to event
During event/ order
After exchange
As a reminder
Need to Know = RELEVANT
RESPONSE TIMING
@DrWendyGuess
What’s needed – When it’s needed!
Formatting Tips:
1-3 topics
3-5 Bullet Points
Visually spaced
Less is More
Hyperlink to detail
Welcome. Wondering about the MyTalk.Rocks?
Link -
http://mytalk.rocks
Rock The Speaker
Send A Photo
Share Feedback
Ask Questions?
@DrWendyGuess
Which “Message” Manager Will YOU Be?
@DrWendyGuess
VS
@DrWendyGuess
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CLINICAL WORKSHEET: NURSING PROCESS CARE PLAN
STUDENT NAME
DATE
Client Initials
Culture/Ethnicity
Support system:
Unit 2 Room/Bed
Religion
Age Sex
Language
Weight Height
Current medical diagnosis
Marital status N/A
Occupation:
Siblings
Name of significant other/primary caregiver
Health insurance :
Current work status N/A
Highest grade completed
Genogram: See attachment
Diagnostic procedures:
Surgical procedures:
Pathophysiology/psychopathology (List reference)
Psychopathology:
(
10
)
DEVELOPMENTAL STAGE/THEORIST
Vital signs/Frequency
Allergies/Side effects
Diet with rationale Activity order
Limitations/prosthetic devices
Theorist:
BRIEF HEALTH HISTORY
PERTINENT LABORATORY
PERTINENT LABORATORY
PERTINENT LABORATORY
PERTINENT LABORATORY DATA
DATA Lab Test #1
DATA Lab Test #2
DATA Lab Test #3
Lab Test #4
Rationale of abnormal results
Results
Rationale of abnormal results
Results
Rationale of abnormal results
Rationale of abnormal results
INTRAVENOUS SOLUTION #1
Type
CC/HR gtts/min
Additives:
Rationale for solution -
INTRAVENOUS SOLUTION #2
MEDICATION NAME
TRADE/GENERIC
DOSAGE ORDERE D
TIMES ADMINISTE RED
DOSE ROUTE
RATIONAL E FOR ADMINIST ERING
THERAPEUTIC RANGE FOR AGE/WEIGHT
NURSING IMPLICATIONS
NURSING DIAGNOSES
LIST IN PRIORITY ORDER (BEGINNING WITH #1 IN
PRIORITY)
DESCRIBE RATIONALE FOR PRIORITY ORDER
UTILIZE A THEORY (NEEDS THEORY/NURSING THEORY)
FOR RATIONALE
(Reference)
ASSESSMENT DATA SUBJECTIVE/ OBJECTIVE
NURSING DIAGNOSIS
PLAN OUTCOME
CRITERIA (CLIENT CENTERED)
INTERVENTIONS (NURSE CENTERED)
RATIONALE FOR INTERVENTIONS
EVALUATION
Include subjective and
objective components.
Assess physiological, psychosocial, developmental, cultural and
spiritual dimensions.
Use a NANDA
diagnosis which has three (3) parts:
•Part I: NANDA statement of nursing problem "
Alternation innutrition: Less thanbody
requirements"
•Part 2: relating to a nursing etiology: "
relating toinadequatenutritional intake"
•Part 3: manifested by the assessed signs and symptoms: "
manifested by lowbody weight
andemaciation."
State the overall plan
as client centered, e.g.,:
•"
The client will..."
Relate the plan to the nursing diagnosis:
Make the
interventions nurse centered.
Indicate what the nurse will do to assist the client in achieving
the outcome criteria, e.g.,
·
The nurse will..."
State frequency/time
/amount so any nurse can carry out the plan:
1)
Document allfood intake for 3days.
2) Determine and make available client's favorite foods by day
2.
3) etc.
State the principle or
scientific rationale for the nursing intervention(s).
Include the reference for the rationale.
Look at the outcome
criteria.
State whether the client achieved the outcome criteria, e.g.,
·
Subjective
Document client's exact words relevant to the diagnosis.
•."
have adequatenutritional intake"
"
The client gained 2
lbs within the past 7days..."
"I'm not hungry"
·
Objective
Document data that is measurable, specific, and relevant to the
nursing diagnosis.
"Weight = 48 Kg" "Lack of subcutaneous fat"
Indicate a measurable outcome criteria by including time
frame/amount/range:
•"
as evidenced by..."
1) the ability to create a balanced meal plan by day (7).
NOTE:
If the outcome criteria was not achieved or only partially
achieved, the nurse needs to go back to the beginning, e.g., the
"assessment" and make revisions or changes as necessary.
2)
gaining 1-2 lbs/wkuntil FDArecommended
weightis achieved.
(3) etc.
ASSESSMENT DATA SUBJECTIVE/ OBJECTIVE
NURSING DIAGNOSIS
PLAN OUTCOME
CRITERIA (CLIENT CENTERED)
INTERVENTIONS (NURSE CENTERED)
RATIONALE FOR INTERVENTIONS
EVALUATION
ASSESSMENT DATA SUBJECTIVE/ OBJECTIVE
NURSING DIAGNOSIS
PLAN OUTCOME
CRITERIA (CLIENT CENTERED)
INTERVENTIONS (NURSE CENTERED)
RATIONALE FOR INTERVENTIONS
EVALUATION
References

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ASSOCIATE SCIENCE IN NURSINGCLINICAL WORKSHEET MATERNITY NU.docx

  • 1. 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
  • 2. 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
  • 3. 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
  • 4. 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
  • 5. Activity Order Limitations/Prosthetic Device PERTINENT LABORATORY DATA Lab Test # 1 Lab Test # 2 Lab Test # 3
  • 6. Lab Test # 4 Hgb/Hct #1 Hgb/Hct #2 Results Results Results Hgb/Hct #3 . Rationale for abnormal results Rationale for abnormal results
  • 7. Rationale for abnormal results Rationale for abnormal results ( 2 ) . 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
  • 8. 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
  • 9. 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
  • 10. Have you received a push notification like this? Real Message: I just want your $$$ @DrWendyGuess Hi John. Your order should be arriving on Thursday. Would you like to set up a date & time to install it? Just reply with your preferences. Wendy Real Message: You care about the customer) Or …. Has a note like this one arrived just at the perfect moment? @DrWendyGuess Which Would YOU Rather Read? Welcome. Wondering about the MyTalk.Rocks? Link -
  • 11. http://mytalk.rocks Rock The Speaker Send A Photo Share Feedback Ask Questions? @DrWendyGuess What’s better for your LTV/ROI? @DrWendyGuess How would it be for your clients to feel like you’re a mind reader? @DrWendyGuess @DrWendyGuess
  • 12. Part 1: Design Campaign What am I really delivering? My guiding principles Beyond the product… For Support To build Community Improve Productivity Create Distraction Or adding to Frustration DESIGN CAMPAIGN @DrWendyGuess Part 2: Customer Journey How do they really feel about it? Are they a hunter or gatherer? Which CTA did they follow?
  • 13. What do they expect to find? What stage are they in? (CRM) What UX concepts are added? CUSTOMER JOURNEY @DrWendyGuess Part 3: Questions/Concerns What do they really need to know about Product/Service? Logistical details A surprise feature How they’ll feel using it Other ways to use product Industry/Insider tips QUESTIONS /CONCERNS @DrWendyGuess
  • 14. Part 4: Response Timing When do they need to know it? At first glance Deep dive After hesitation Leading up to event During event/ order After exchange As a reminder Need to Know = RELEVANT RESPONSE TIMING @DrWendyGuess What’s needed – When it’s needed! Formatting Tips: 1-3 topics 3-5 Bullet Points Visually spaced Less is More Hyperlink to detail Welcome. Wondering about the MyTalk.Rocks? Link - http://mytalk.rocks
  • 15. Rock The Speaker Send A Photo Share Feedback Ask Questions? @DrWendyGuess Which “Message” Manager Will YOU Be? @DrWendyGuess VS @DrWendyGuess image7.jpg image4.png image10.jpg image5.png image9.jpg image3.png image1.png image11.jpg image21.jpg image24.jpg image22.jpg image2.png image12.jpg image6.png image14.jpg
  • 16. image17.png image16.jpg image19.png image18.jpg image23.png image20.png CLINICAL WORKSHEET: NURSING PROCESS CARE PLAN STUDENT NAME DATE Client Initials Culture/Ethnicity Support system: Unit 2 Room/Bed Religion Age Sex Language Weight Height Current medical diagnosis Marital status N/A Occupation: Siblings Name of significant other/primary caregiver Health insurance : Current work status N/A
  • 17. Highest grade completed Genogram: See attachment Diagnostic procedures: Surgical procedures: Pathophysiology/psychopathology (List reference) Psychopathology: ( 10 ) DEVELOPMENTAL STAGE/THEORIST Vital signs/Frequency Allergies/Side effects Diet with rationale Activity order Limitations/prosthetic devices Theorist:
  • 18. BRIEF HEALTH HISTORY PERTINENT LABORATORY PERTINENT LABORATORY PERTINENT LABORATORY PERTINENT LABORATORY DATA DATA Lab Test #1 DATA Lab Test #2 DATA Lab Test #3 Lab Test #4 Rationale of abnormal results Results Rationale of abnormal results Results
  • 20. Rationale of abnormal results INTRAVENOUS SOLUTION #1 Type CC/HR gtts/min Additives: Rationale for solution - INTRAVENOUS SOLUTION #2 MEDICATION NAME TRADE/GENERIC DOSAGE ORDERE D TIMES ADMINISTE RED DOSE ROUTE
  • 21. RATIONAL E FOR ADMINIST ERING THERAPEUTIC RANGE FOR AGE/WEIGHT NURSING IMPLICATIONS NURSING DIAGNOSES LIST IN PRIORITY ORDER (BEGINNING WITH #1 IN PRIORITY) DESCRIBE RATIONALE FOR PRIORITY ORDER UTILIZE A THEORY (NEEDS THEORY/NURSING THEORY) FOR RATIONALE
  • 22. (Reference) ASSESSMENT DATA SUBJECTIVE/ OBJECTIVE NURSING DIAGNOSIS PLAN OUTCOME CRITERIA (CLIENT CENTERED) INTERVENTIONS (NURSE CENTERED) RATIONALE FOR INTERVENTIONS EVALUATION Include subjective and objective components. Assess physiological, psychosocial, developmental, cultural and spiritual dimensions. Use a NANDA diagnosis which has three (3) parts: •Part I: NANDA statement of nursing problem " Alternation innutrition: Less thanbody requirements"
  • 23. •Part 2: relating to a nursing etiology: " relating toinadequatenutritional intake" •Part 3: manifested by the assessed signs and symptoms: " manifested by lowbody weight andemaciation." State the overall plan as client centered, e.g.,: •" The client will..." Relate the plan to the nursing diagnosis: Make the interventions nurse centered. Indicate what the nurse will do to assist the client in achieving the outcome criteria, e.g., · The nurse will..." State frequency/time /amount so any nurse can carry out the plan: 1) Document allfood intake for 3days.
  • 24. 2) Determine and make available client's favorite foods by day 2. 3) etc. State the principle or scientific rationale for the nursing intervention(s). Include the reference for the rationale. Look at the outcome criteria. State whether the client achieved the outcome criteria, e.g., · Subjective Document client's exact words relevant to the diagnosis. •." have adequatenutritional intake" " The client gained 2 lbs within the past 7days..." "I'm not hungry" · Objective Document data that is measurable, specific, and relevant to the nursing diagnosis. "Weight = 48 Kg" "Lack of subcutaneous fat"
  • 25. Indicate a measurable outcome criteria by including time frame/amount/range: •" as evidenced by..." 1) the ability to create a balanced meal plan by day (7). NOTE: If the outcome criteria was not achieved or only partially achieved, the nurse needs to go back to the beginning, e.g., the "assessment" and make revisions or changes as necessary. 2) gaining 1-2 lbs/wkuntil FDArecommended weightis achieved. (3) etc. ASSESSMENT DATA SUBJECTIVE/ OBJECTIVE NURSING DIAGNOSIS PLAN OUTCOME CRITERIA (CLIENT CENTERED)
  • 26. INTERVENTIONS (NURSE CENTERED) RATIONALE FOR INTERVENTIONS EVALUATION ASSESSMENT DATA SUBJECTIVE/ OBJECTIVE NURSING DIAGNOSIS PLAN OUTCOME CRITERIA (CLIENT CENTERED) INTERVENTIONS (NURSE CENTERED) RATIONALE FOR INTERVENTIONS EVALUATION