Chief Complaint
Contractions, rupture of membrane or bleeding.
Admitting Diagnosis
NSVD, or C-Section
Medical Conditions
Patient Information
(1)
Name:
Age:
Height/Weight:
Allergies:
Gestational Age:
Admitting Dx (Cite References) Medical, Surgical, Social History and OB History
Medical History
Surgical History
Social History
Obstetric History
GTPAL
Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14)
Medical Management/ Orders/ Medications & Allergies (2)
Name
Dose
RT
Freq.
MOA
RN Considerations
Onset/Peak/Duration
(Insulin)
Erickson’s Developmental Stage Related to pt. & Cite References (1)
Patient Education (In Pt.) & Discharge Planning (home needs )
Diagnostic Test/ Lab Results with dates and Normal Ranges (3)
Test
Norms
Date
Current Value
Concept Map
Student Name:
Instructor:
PC Outcomes/Goal
Priority nursing diagnosis #2
Respiratory (7)
Vital Signs (4)
Integumentary (12)
Interventions # 2
Assessment/ Evaluation #1
Assessment/ Evaluation #2
PC Evaluation Plan
Potential Complications/ at risk for
PC Interventions
Psychosocial (14)
Cardiovascular (6)
Endocrine (13)
Misc. (Ht/Wt)
GU (10)
GI (9)
Nutrition/Hydration
(8)
Rest/ Exercise (11)
Neurological (5)
Outcome/Goal #1
Priority nursing diagnosis #1
Outcome/Goal #2
Interventions #1
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