Labor & Delivery Clinical Experience Name: Date of clinical: Data Collection Patient initials: Patient age Admission date Support person Mother G P T A L Gestational age OB history Allergies Medical history Surgical history Delivery plan Blood type and RH GBS Hep B Rubella HIV RPR STIs H&H Platelets If any lab values are abnormal, describe the potential impact to the mother and fetus: Current Medications Home Medications Labor Assessment Augmentation If yes, how was labor augmented? Spontaneous Induction If yes, onset of labor time If yes, reason for induction Vaginal Exam Rupture of membranes Dilation SROM or AROM Pain management Effacement Time Station Color Fetal presentation Fetal monitoring Elements Baseline heart rate Variability Accelerations Found on your patient Possible findings or normal ranges Decelerations Contraction frequency Contraction duration Contraction intensity Uterine resting tone Birth Type of delivery Time Complications Lacerations or episiotomy? Repair? Gender of baby Apgar score Skin-to-skin time Patient Assessment Vital signs: Neurological: Respiratory: Cardiovascular: Gastrointestinal: Genitourinary: Musculoskeletal: Skin: Endocrine (Include Blood Sugars): Pain/Sensory: Intake & Output: Psychosocial: Nursing Process Diagnosis List two nursing diagnoses for this patient (include all three parts- the diagnosis, the related to, and the evidence) Planning Create one SMART goal for your patient during your shift Implementation List three interventions to reach your SMART goal Evaluation Did the patient meet the goal? Reflection Who was present with your patient during labor and birth? Did they actively participate with the patient during the process? Describe. How did your patient respond to the discomforts of labor and to her partner/coach (if any)? What pain management interventions were used and which measures seemed to help the most? (include both pharmacologic and non -pharmacologic interventions) What were the indications that suggested progress or lack of progress in labor? Describe the response of the fetus to labor (variability, periodic changes such as accelerations or decelerations). If present, what did the nurse do to intervene?