The document outlines a detailed clinical worksheet for maternity nursing, including sections on patient demographics, medical history, diagnostic procedures, medications, and nursing care plans. It emphasizes the importance of assessment data, nursing diagnoses, interventions, and evaluation in providing patient-centered care. Additionally, it highlights the necessity of rationales for nursing actions and the incorporation of theories in the nursing process.

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

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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
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@DrWendyGuess
Which Would YOU Rather Read?
Welcome. Wondering about the MyTalk.Rocks?
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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

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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

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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
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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

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

19. Rationale of abnormal 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

27. References