Carla Hernandez Vsim

I need to complete the care plan using the Carla Hernandez vsim maternity

also I upload the document that I have to fill with the information

New Professions Technical Institute

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
		.
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

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