Postpartum Clinical Rotation Worksheet
Student: ______________
Date:
Faculty:
PP Vaginal Delivery PP C-Section Delivery (circle one)
Client’s Initials___________ Age: ______ G___ T___ P___ A___ L___ (post delivery)
Date of Admission: __________ Allergies: ________
EDD: ________ Date of Delivery: _________ Gestational Age at delivery: ______Weeks
ROM: SROM __ __ AROM _____ Date/Time of Rupture _________ Fluid color: ________
EBL at delivery: _________
Time of Delivery: _____ Sex:_____ Apgar Scores: _____ Newborn Weight at Delivery: _____
Method of Infant Feeding: _____
Significant Past OB/Medical/Surgical History:
Psychosocial History:
Labor/Delivery Complications/Interventions (include if any delivery interventions: pain management, unplanned C-section, episiotomy/laceration, elevated temperatures, HTN,
etc)
Assessment on Transfer to Postpartum
Maternal V/S on admission to postpartum: B/P__ T __ P __ R__ Pain: ___
Maternal V/S at start of shift: B/P ______ P __ R____ O2 Sat ___ Pain: ____
Significant Laboratory and Diagnostic Studies (if postpartum patient must list both admission and postpartum H&H and state what it means in relation to estimated blood loss
(EBL)):
Admitting labs:
Blood Type HSV GBS AST BUN Uric Acid
WBC G/C RPR ALT Creatinine Blood Glucose #1
H&H HIV Rubella LDH Mag Level Blood Glucose #2
Platelet Hep B
Postpartum Complications (include any obstetrical, psychosocial or newborn issues):
Postpartum interventions (what you did for your patient, including a B-U-B-B-L-E-H-E assessment):
Additional postpartum questions:
1. Should this patient receive postpartum Rhogam? Under what circumstances might a postpartum patient need Rhogam? How is Rhogam administered?
2. Should this patient receive a Rubella vaccine prior to discharge? What titer values would indicate the need for Rubella vaccine? How is a Rubella vaccine administered?
What topics should be discussed during her postpartum teaching? What other topics should be included in discharge teaching for this mother and her baby?
Nursing Diagnosis List and Care Plan – Prioritized Care plan to include three Dx. (Plan to include two goals/expected outcomes for each nursing diagnosis and three
interventions with rationales per goal/expected outcome.)
Problem Goals Interventions Evaluation
Nursing Evaluation
Diagnosis: Goal #1 1.
2.
Example: 3.
Nursing Diagnosis #1
Goal #2 1. Evaluation
Required: 2.
3.
You need the following:
3 Nursing Diagnosis
Related To or As Evidenced
By:
Signs & Symptoms:
2 Goals per Nursing
Diagnosis
3 Interventions per Goal
1 Evaluation per goal
Medications: Include 1V fluids and IVPBs as applicable
Order 1: Acetaminophen 300mg/Codeine 30mg 1 or 2 tabs by mouth every six hours PRN for pain 5 or more on 1-10 scale.
Assume the patient’s postpartum blood loss continues to be very heavy (soaking a peri pad every 15 minutes) with lingering uterine atony unrelieved
by fundal massage.
Order 2: Methergine 0.2 mg IM q2-4hr PRN; not to exceed 5 doses
Medications/ Dose, Range, Route Time Schedule Side Effects Action Rationale for
Classification Drug Therapy
