COURSE SYLLABUS
RNSG 2462 (4:0:16)
CLINICAL NURSING: MATERNAL/CHILD
**********
ASSOCIATE DEGREE NURSING PROGRAM
DEPARTMENT OF NURSING
HEALTH OCCUPATION DIVISION
LEVELLAND CAMPUS
SOUTH PLAINS COLLEGE
SPRING 2011
SCANS COMPETENCIES
RESOURCES: Identifies, organizes, plans and allocates resources.
C-1
TIME--Selects goal--relevant activities, ranks them, allocates time, and prepares and follows schedules.
C-2
MONEY--Uses or prepares budgets, makes forecasts, keeps records, and makes adjustments to meet objectives
C-3
MATERIALS & FACILITIES-Acquires, stores, allocates, and uses materials or space efficiently.
C-4
HUMAN RESOURCES--Assesses skills and distributes work accordingly, evaluates performances and
provides feedback.
INFORMATION--Acquires and Uses Information
C-5
Acquires and evaluates information.
C-6
Organizes and maintains information.
C-7
Interprets and communicates information.
C-8
Uses computers to Process information.
INTERPERSONAL--Works With Others
C-9
Participates as members of a team and contributes to group effort.
C-10
Teaches others new skills.
C-11
Serves clients/customers--works to satisfy customer's expectations.
C-12
Exercises leadership--communicates ideas to justify position, persuades and convinces others, responsibly
challenges existing procedures and policies.
C-13
Negotiates-Works toward agreements involving exchanges of resources resolves divergent interests.
C-14
Works with Diversity-Works well with men and women from diverse backgrounds.
SYSTEMS--Understands Complex Interrelationships
C-15
Understands Systems--Knows how social, organizational, and technological systems work and operates
effectively with them
C-16
Monitors and Correct Performance-Distinguishes trends, predicts impacts on system operations, diagnoses
systems' performance and corrects malfunctions.
C-17
Improves or Designs Systems-Suggests modifications to existing systems and develops new or alternative
systems to improve performance.
TECHNOLOGY--Works with a variety of technologies
C-18
Selects Technology--Chooses procedures, tools, or equipment including computers and related technologies.
C-19
Applies Technology to Task-Understands overall intent and proper procedures for setup and operation of
equipment.
C-20
Maintains and Troubleshoots Equipment-Prevents, identifies, or solves problems with equipment, including
computers and other technologies.
FOUNDATION SKILLS
BASIC SKILLS--Reads, writes, performs arithmetic and mathematical operations, listens and speaks
F-1
Reading--locates, understands, and interprets written information in prose and in documents such as manuals,
graphs, and schedules.
F-2
Writing-Communicates thoughts, ideas, information and messages in writing, and creates documents such as
letters, directions, manuals, reports, graphs, and flow charts.
F-3
Arithmetic--Performs basic computations; uses basic numerical concepts such as whole numbers, etc.
F-4
Mathematics--Approaches practical problems by choosing appropriately from a variety of mathematical
techniques.
F-5
Listening--Receives, attends to, interprets, and responds to verbal messages and other cues.
F-6
Speaking--Organizes ideas and communicates orally.
THINKING SKILLS--Thinks creatively, makes decisions, solves problems, visualizes, and knows how to learn
and reason
F-7
Creative Thinking--Generates new ideas.
F-8
Decision-Making--Specifies goals and constraints, generates alternatives, considers risks, and evaluates and
chooses best alternative.
F-9
Problem Solving--Recognizes problems and devises and implements plan of action.
F-10
Seeing Things in the Mind's Eye--Organizes and processes symbols, pictures, graphs, objects, and other
information.
F-11
Knowing How to Learn--Uses efficient learning techniques to acquire and apply new knowledge and skills.
F-12
Reasoning--Discovers a rule or principle underlying the relationship between two or more objects and applies it
when solving a problem.
PERSONAL QUALITIES--Displays responsibility, self-esteem, sociability, self-management, integrity and
honesty
F-13
Responsibility--Exerts a high level of effort and preservers towards goal attainment.
F-14
Self-Esteem--Believes in own self-worth and maintains a positive view of self.
F-15
Sociability--Demonstrates understanding, friendliness, adaptability, empathy, and politeness in group settings.
F-16
Self-Management--Assesses self accurately, sets personal goals, monitors progress, and exhibits self-control.
F-17
Integrity/Honesty--Chooses ethical courses of action.
SOUTH PLAINS COLLEGE
ASSOCIATE DEGREE NURSING PROGRAM
CLINICAL NURSING MATERNAL/CHILD
TABLE OF CONTENTS
COURSE SYLLABUS ...................................................................................................................1
Course Description...............................................................................................................1
Course Learning Outcomes..................................................................................................2
Course Competencies...........................................................................................................3
Academic Integrity...............................................................................................................3
Scans and Foundation Skills ................................................................................................3
Verification of Workforce Competencies ............................................................................4
SPECIFIC COURSE/INSTRUCTOR REQUIREMENTS .......................................................4
Required Text.......................................................................................................................4
Recommended Text .............................................................................................................4
Attendance Policy ................................................................................................................5
Assignment Policy ...............................................................................................................5
Grading Policy .....................................................................................................................5
Special Requirements...........................................................................................................5
Accommodation ...................................................................................................................8
REQUIREMENTS:
Responsibility Notebook Instructions ..................................................................................9
Student Responsibility Folder ............................................................................................10
Computer Assisted Instructions .........................................................................................11
OB Videos ..........................................................................................................................13
Pedi Videos ........................................................................................................................14
CLINICAL EVALUATION TOOLS.........................................................................................15
UNIT SPECIFIC CLINICAL OBJECTIVES (SITE TOOLS) ...............................................35
UMC STUDENT ORIENTATION PACKETS
NICU
PERINATAL AREAS
PEDIATRICS AND PICU
SOUTHWEST CANCER CENTER
Campuses:
Levelland
COURSE SYLLABUS
COURSE TITLE:
RNSG 2462 Clinical Nursing: Maternal/Child
INSTRUCTORS:
Jill Pitts, RNC, MSN
Lourie Winegar, RN, MSN
Ray Hughes, RN, MSN
Jennifer Payne, RN, BSN
Denise Glab, RN,MSN
OFFICE LOCATION AND PHONE/E-MAIL:
Jill Pitts
TA 133, 894-9611 Ext. 2385, jpitts@southplainscollege.edu
Pager 761-6809, 894-5288 (home), 787-0997 (cell)
Lourie Winegar
TA128, 894-9611, Ext. 2383, lwinegar@southplainscollege.edu
544-3736 (Cell)
Ray Hughes
TA 110, 894-9611, Ext 2391. rhughes@southplainscollege.edu
544-7479 (Cell)
Jennifer Payne
TA 110, 894-9611, Ext 2391, jpayne@southplainscollge.edu
281-4796 (Cell)
Denise Glab
(806)773-2017 dglab@southplainscollege.edu
OFFICE HOURS:
Posted on each instructor’s door.
SOUTH PLAINS COLLEGE IMPROVES EACH STUDENT’S LIFE
I.
GENERAL COURSE INFORMATION
A. COURSE DESCRIPTION
RNSG 2462, an introduction to Maternal-Child nursing, is designed to provide the
learner with basic knowledge and skills to function within the three roles of nursing
(provider of care, coordinator/manager of care, and member of the profession) while
working with clients, families, and/or groups in the childbearing/childrearing stages
of life in a variety of settings. This course focuses on the care of the bio-psychosocio-spiritual childbearing/childrearing stages of life in a variety of settings. This
course focuses on the care of the bio-psycho-socio-spiritual childbearing/childrearing
family through the use of critical thinking/problem solving, delegation, and nursing
process within an interpersonal and collaborative framework in clinical settings.
Supportive foundation knowledge needed to care for the childbearing/childbearing
individual, family, and community includes physical and emotional aspects of nursing
care, integrating developmental, nutritional, and pharmacological concepts. Also
essential in success are concepts of communication, safety, legal ethical issues,
current technology, economics, humanities and biological, social and behavioral
sciences.
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This course assists the student in identifying teaching and learning needs and
community resources for the client/families and/or groups while serving as a health
care advocate in achieving optimal wellness. The maternal-child nursing student will
recognize a commitment to professional growth, continuous learning, and selfdevelopment. This course must be taken concurrently with RNSG 1412.
1. Meet all requirements for admission into the Associate Degree Nursing Program.
2. Prerequisites: RNSG 1513,1205, 1160, 1115, 1443, 2460, 2213. BIOL 2402,
2420. PSYC 2314.
3. Placement: Spring 2011
4. Time Allotment: Sixteen (16) weeks. The course allows four- (4) semester hour
credits. This includes sixteen (16) hours of clinical experience each week.
5. Teaching Strategies: nursing laboratory, simulated lab, audiovisual media, student
presentations, and group discussion, selected case presentation material, review of
journal articles, study guides, patient care conference, computer programs, and
individual and multiple client assignments.
6. Teaching Personnel: Associate Degree Nursing faculty; guest speakers.
B. COURSE LEARNING OUTCOMES
Upon successful completion of RNSG 2462 the student will meet all Level III
Educational Outcomes as specifically applied to the childbearing and/or childrearing
family. Additional specific information and objectives are found in the course
description, and the clinical evaluation tool.
PROVIDER OF CARE:
1. Integrate theoretical concepts of the bio-psycho-socio-spiritual sciences with nursing
knowledge and skills to meet the basic needs of clients, families, and/or groups throughout
the life span in a variety of settings.
2. Integrate the five steps of the nursing process into nursing practice.
3. Communicate and collaborate effectively with clients, families, and/or groups in a variety of
settings.
4. Provide safe, cost-effective nursing care in collaboration with members of the health care
team using critical thinking, problem solving, and the nursing process in a variety of settings
through direct care, assignment or delegation of care.
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5. Integrate principles of teaching-learning in providing information to clients, families, and/or
groups regarding promotion, maintenance, and restoration of health or the process of death
and dying.
6. Evaluate responses and outcomes to therapeutic interventions, clinical data, and current
literature to make appropriate nursing practice decisions.
MANAGER/COORDINATOR OF CARE:
1. Determine the function within the organizational framework of various health care settings.
2. Evaluate the effectiveness of community resources in the delivery of health care to clients,
families, and/or groups.
3. Coordinate the health care team in delivering care to clients, families, and/or groups.
4. Coordinate appropriate referral sources to meet the needs of clients, families, and/or groups.
5. Utilize critical thinking and problem solving skills in the management and coordination of all
aspects of care.
MEMBER OF THE PROFESSION:
1. Assume responsibility for professional and personal growth and development.
2. Assume ethical and legal responsibility for one’s nursing practice.
3. Act as a health care advocate to provide quality health care for clients, families and/or group.
4. Demonstrate caring behavior when interacting with clients, family, and members of health
care profession.
C. COURSE COMPETENCIES
Successful completion of this course requires a minimum of 77% of site tool grades
must be a 2 or above must be met in order to pass RNSG 2462. All starred clinical
objectives and lettered objectives on the evaluation tools must be met with a score of
2 or better on the final evaluation. Regular clinical attendance is required. Upon
successful completion of this course, each student will have demonstrated
accomplishment of the level objectives for the course, through a variety of modes.
D. ACADEMIC INTEGRITY
Refer to the SPC College Catalog. Refers to the SPC ADNP Nursing student
handbook “Honesty Policy”.
E. SCANS AND FOUNDATION SKILLS
Scans and foundation skills found within this course are listed below the unit title and
above the content column of each unit.
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F. VERIFICATION OF WORKPLACE COMPETENCIES
External learning experiences (clinicals) provide workplace setting in which students
apply content and strategies related to program theory and management of the
workflow. Successful completion of the ELC statements at the level specified by the
course (Level Outcomes) will allow the student to continue to advance within the
program. Upon successful completion of the program students will be eligible to
apply to take the state board exam (NCLEX) for registered nurse licensure.
II.
SPECIFIC COURSE/INSTRUCTOR REQUIREMENT
A. TEXTBOOK AND OTHER MATERIAL
Required Texts
James, S., & Ashwill, J. (2007) Nursing Care of Children: Principles and
Practice. (3rd Edition) Philadelphia, PA. W. B. Saunders.
James, S., & Ashwill, J. Study Guide
Murray, S. & McKinney, E. (2010). Foundations of Maternal-Newborn Nursing and
Woman’s Health Nursin. (5th Ed.). Philadelphia, PA. W. B. Saunders.
Murray, S., McKinney, E., Study Guide
Taketome, Hodding, & Kraus (2009 or 2010). Lexicomp’s Pediatric Dosage
Handbook. (16th or 17th Edition)
* * Drug Book of Choice
* * Medical Dictionary of Choice
Recommended Texts
Mosby’s Nursing Video Skills: Maternal, Newborn & Women’s Health
Mosby’s Nursing Video Skills: Care of Infants and Children
Hamlisch, B.W., (2007). Virtual Clinical Excursions-Pediatricst for Nursing
Care of Children: Principles and Practice, for James, &
Ashwill.Philadelphia: Saunders.
Caphio & Crio(2006). Virtual Clinical Excursions for Foundations of
Maternal-Newborn Nursing. Philadelphia: Saunders.
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B. ATTENDANCE POLICY
The SPC ADNP policy must be followed. Refer to the SPC ADNP Student Nurse
handbook to review this policy. In addition, refer to the attendance policy found in
the South Plains College Catalog.
C. ASSIGNMENT POLICY
1.
Completion of Student Contract for RNSG 1412 and RNSG 2462.
2. Site tools (on WebCT) are due the beginning of class on Tuesday after clinical
rotations are completed. The student must have unit scores of 2 or better on 77%
of their tools to pass RNSG 2462. The tool will be given a 0 unit score if it is
late; however, all tools must be complete and turned in to pass RNSG 2462.
3. Student must achieve an 77% average on the following assignments: teaching
project or article presentation counts 20%; Pediatric Database counts 20%;
Obstetric Database counts 20%; Stages of Labor counts 20%; and Nursing
Processes average counts 20%.
D. GRADING POLICY
1. This course is assigned a pass/fail grade status.
2. A minimum of 77% of site tool unit grades must be a 2 or above to pass RNSG
2462.
3. An 77% average must be achieved on clinical assignments.
4. All starred and lettered clinical objectives on the final clinical evaluation tool
must be met with a score of 2 or better to pass RNSG 2462.
5. All make-up assignments must be completed as assigned with a grade of 77% or
better to pass RNSG 2462. If the make-up assignment is more than one week late
it will be given a grade of zero and an additional assignment must be completed.
6. Failure of either theory or clinical will necessitate repeating all concurrent
courses. When repeating any course, the student is required to retake all aspects
of the course including the required written work.
E. SPECIAL REQUIREMENTS
A. Clinical Component
1. Refer to the first three pages of the clinical evaluation tool for clinical grading
criteria.
2. When students exhibit inappropriate behavior, i.e., tardiness to clinical or
skills lab, the instructor of that student will handle the situation with his/her
discretion.
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3. No cell phones may be carried on the student during clinical rotations. You
may not make personal phone calls during clinicals without instructor
permission unless it is during your lunch break. If you bring a cell phone in
your bag, it must be turned off or on silent mode to avoid interruptions.
Students who violate this guideline may be removed from the clinical setting.
4. Students are expected to attend all scheduled days of clinical experience. In
the event of illness, it is the student's responsibility to notify his/her instructor.
The student is to call the clinical area he/she is assigned to that day before the
start of the workday. Should the student miss a clinical day, a Contact Record
will be completed. This record will indicate the additional assignment
required and dates for completion. Failure to notify the instructor of an
absence or early dismissal from a clinical rotation will result in a Formal
Learning Contract specifying the additional assignment.
Should a third absence occur, the student will be referred to the ADNP
Admission/Academic Standards Committee with the instructor's
recommendations. The student's right of appeal is through the ADNP
Admission/Academic Standards Committee. The instructor has the
prerogative of dropping the student from the course. If the student is in good
standing clinically, has properly notified the instructor when absent, and
resolved the problem causing the absence, the instructor has the option to
allow the student to continue in the course. Additional assignments for
missed clinical experience may be used at the instructor's discretion.
On the fourth absence from clinical experience, the student will automatically
be given a failing grade in the nursing course unless it is a hardship case.
Extenuating problems such as surgery, severe illness, pregnancy delivered or
family emergency may be requested as a hardship case by appointment with
the ADNP Admission/Academic Standards Committee. The student must
bring a statement of the problem signed by the instructor to this conference.
B. Skills Lab/ Simulation lab
1. Students are expected to attend all scheduled skill lab experiences. A skills
lab absence counts as a clinical absence. The student cannot perform missed
skills lab procedures in the clinical setting until successful completion is
demonstrated to the lab instructor.
2. Audiovisual, films are considered part of the skills lab. A summary of each
film viewed is to be placed in the student responsibility folder.
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C. Clinical Responsibilities
1. It is the student's responsibility to seek opportunities during his/her clinical
experience to meet the required clinical goals and complete the clinical
evaluation and site tools for each assigned clinical area. The clinical
evaluation tool and site tool should be reviewed prior to each clinical day, in
order to insure objective completion. The unit specific site tools should be
completed and submitted weekly to an instructor. Each objective on the
evaluation tool must be validated by the student by the end of each evaluation
period.
2. A minimum of two scheduled clinical evaluation sessions per semester is
required (Midterm and final evaluations). More sessions may be scheduled
based on student-instructor identified need.
3. The clinical instructor may remove the student from the clinical setting if the
student demonstrates unsafe clinical performance as evidenced by the
following:
a). Is inadequately prepared for clinical.
b). Places a client in physical or emotional jeopardy.
c). Inadequately and/or inaccurately utilizes the nursing process.
e). Violates previously mastered principles/learning/objectives in carrying out
nursing care skills and/or delegated medical functions.
f). Assumes inappropriate independence in action or decisions. The student
may not suggest referrals for patients – please notify the TPCN for
concerns related to referrals. Students cannot initiate infant adoption
arrangements.
g). Fails to recognize own limitations, incompetence and/or legal
responsibilities.
h). Fails to accept moral and legal responsibility for his/her own actions;
thereby, violating professional integrity.
i). Noncompliance with SPC ADN dress code.
j). Lack of initiative and self-direction.
k). Displays unprofessional conduct.
4. No photocopies of any part of the patient’s chart or actual parts of the patients
chart may be removed from the hospital or clinic by the student. This is a
breach of confidentially and students will be dismissed from the class and/or
program for violating this guideline.
5. Prior to the end of the semester, each student will be expected to provide total
patient care to two or more clients daily.
6. Each student is expected to be knowledgeable regarding the Nurse Practice
Act in respect to professional performance, including delegation rules.
7. Lab prescriptions - a prescription will be assigned by the clinical instructor for
any specific skill that he/she decides needs further practice.
8. The SPC Uniform Policy must be followed in all clinical areas (both hospital
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and community). See the ADNP Student Handbook.
9. Each student will have and maintain a responsibility notebook through out the
semester. Every item required must be completed and turned in at specified
intervals.
10. Medication Administration: Refer to Medication Administration Policy in
Student Handbook (Levels I,II, and III pertain to this semester) and
Preparation of Pediatric Medication sheet in syllabus
11. The student is expected to review clinical site preparation recommendations,
the study guides and orientation packets in the syllabus prior to attending
clinical rotations in those areas of the hospital. The antepartum study guide
must be completed and turned in for grading (date TBA).
III.
ACCOMMODATIONS
Accommodations--Special Requirements
Students with disabilities, including but not limited to physical, psychiatric, or learning
disabilities, who wish to request accommodations in this class should notify the Special
Services Office. In accordance with federal law, a student requesting accommodations
must provide acceptable documentation of his/her disability to the Special Services
Coordinator. For more information, call or visit the Special Services Office in the
Student Services Building, 894-9611 ext. 2529, 2530.
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RNSG 1412 & 2462
Maternal – Child Nursing
Student Name: ___________________________
Responsibility Notebook Instructions
You will need a 1 inch size three ring binder and 5 tab pages for this course.
Please put your name on the front of the notebook.
Notebook arrangement:
This page should be placed first in the notebook.
Tab page 1 should be labeled “Computer Programs”
Place page 11 & 12 of the syllabus behind this tab page
Tab page 2 should be labeled “Site Tools”
Place graded site tools behind this tab as they are returned to you
Tab page 3 should be labeled “Clinical Evaluation Tools”
Place your Midterm and Final Evaluations here to turn in for grading at the designated
times within the semester (pages 15 – 34).
Tab page 4 should be labeled “Videos Check Off Sheet”
Place your check off sheet and your handwritten notes of the videos you watched the first
week of class here.
Tab page 5 should be labeled “Nursing Process”
Place your grade processes behind this tab.
This notebook should be turned in for grading at these times:
**The second Tues. of class for grading video notes and to check notebook arrangement
**For the midterm evaluation (see syllabus page 18 for required information that should
be included for the midterm clinical evaluation)
**For the final evaluation (see syllabus page 18 for required information that should be
included for the final clinical evaluation)
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MATERNAL/CHILD HEALTH COMPUTER ASSISTED INSTRUCTIONS
Minimum of seven computer programs must be completed prior to the midterm clinical
evaluation. No cell phones or USB ports are allowed in the computer lab.
MATERNAL
DATE
VIEWED
INSTRUCTOR
INITIAL
*Labor and Delivery Drugs
Maternity Nursing I (Medi-Sim):
*1. Normal Labor, Birth, and Postpartum
2. A Complicated Delivery: Prolonged Labor
*3. Assessment of a Newborn
4. A Pregnancy Complicated by PIH
Maternity Nursing II (Medi-Sim)
*5. A Maternity Client at Risk
6. Preterm Labor and Care of a Premature Infant
7. A Pregnancy complicated by a STD
8. Adolescent pregnancy and prenatal education
Clinical Skills 2:
Epidural anesthesia
*REQUIRED VIEWING
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RNSG 2462
MATERNAL/CHILD HEALTH COMPUTER ASSISTED INSTRUCTIONS
DATE
VIEWED
PEDIATRIC
INSTRUCTOR
INITIAL
Pediatric Nursing I (Medi-Sim):
1.
An Infant With Vomiting
2.
A Toddler Hospitalized Following a Seizure
3.
A Preschooler With Meningitis
4.
A School-Aged Child With a Head Injury
5. Neonatal & Pediatric Critical Care:
6.
Alterations in Fluid & Electrolytes
7.
Meconium Aspiration
8.
Alterations in Neurologic Function
Respiratory Distress Syndrome
Other computer programs available to enhance learning:
Drugs in Pregnancy & lactation (resource)
Incredibly Easy CD's:
Maternal-Neonatal Nursing
Pediatric Nursing
Test Taking-RN
*REQUIRED VIEWING
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OBSTETRIC VIDEO
D004
D001
D002
D003
D018
D022
D023
D024
D025
D028
D036
D038
D041
D045
DO51
D054
D056
D058
REDUCING RISK FACTORS - CONCEPTION TO NEONATE
MIRACLES OF LIFE
C-SECTION
BORN DRUNK
STATE OF THE FUTURE OBSTETRICS:
FCMC/MOTHER-BABY NSG.
SATURDAY'S CHILDREN-3/4"
EIGHT STAGES OF THE HUMAN LIVE w/ Teacher's Guide
DOPPLER, ULTRASOUND, STETHOSCOPE
MARCH OF DIMES: WOMAN-CHILD
BIRTHS
NURSING MANAGEMENT OF HYPERTENSION IN PREGNANCY
POSTPARTUM NURSING ASSESSMENT:
THE 12 POINT CHECK W/ STUDY
GUIDE
NAACOG-EXTERNAL FETAL MONITORING, INSTRUMENTATION,
AND INTERPRETATION
PREGNANCY: MOM AND THE UNBORN BABY (70:00)
BIRTH AND THE FIRST FOUR WEEKS
GESTATIONAL DIABETES (32:00)
"HELLO BABY"
CROSS TRAINING FOR OBSTETRICAL NURSING STAFF
13
PEDIATRIC VIDEOS
D005
D006
D007
D008
D009
D020
D021
D029
D031
D032
D033
D035
D039
D040
D042
D043
D044
D046
D047
D048
D049
D050
D052
D053
D055
D055
D058
S031
P037
BABY BASICS
BILIRUBIN/ANTHROPOMETRY: THE NATURE OF MILK
AJN ABREAST FEEDING: A PRACTICAL GUIDE (PARTS 1 & 2)
TOUCH BY JOHNSON AND JOHNSON
FETAL MONITORING OPERATING GUIDE BY HEWLETT PACKARD
EXAM OF THE NEWBORN
BORN DRUNK
AMAZING NEWBORN
TIES THAT BIND
TO BREAST-FEED YOUR BABY
TO FORMULA FEED YOUR BABY
BREAST-FEEDING: A PRACTICAL GUIDE, PART 1
BREAST-FEEDING: A PRACTICAL GUIDE, PART 2
CEREBRAL PALSY
FETAL-NEONATAL ASPHYXIA
AN INTRODUCTION: THE BREAST-FEEDING MOTHER
JAUNDICE IN THE NEWBORN
ANTERIOR WALL DEFECTS
FIRST DAYS OF LIFE
INFANT MOTOR DEVELOPMENT LOOK AT THE PHASES
POSITIONING FOR ACTIVITY-ALIGNMENT TECHNIQUES FOR POSITIONING
PHYSICALLY CHALLENGED CHILDREN FOR ACTIVITY
DR. HARMON-PEDI ASSESSMENT OF CARDIAC PATIENTS
CHILD ABUSE AND NEGLECT-THE HIDDEN HURT
BREAST-FEEDING YOUR BABY: BREAST-FEEDING, COMBINED, BOTTLE
BABY CARE BASICS FOR YOUR BABY'S EARLY MONTHS
CHILDHOOD I-THE INFANT CHILD (4 WEEKS TO 18 MONTHS)
PROMOTING NORMAL GROWTH IN THE HOSPITALIZED CHILD
CARE OF HIV-INFECTED CHILDREN (28:30) W/ STUDY GUIDE
SURVIVAL SKILLS FOR DIABETIC CHILDREN (29:10) W/STUDY
GROWTH & DEVELOPMENT-INFANT, TODDLER, SCHOOL AGE,
ADOLESCENT (D013-17) W/PROGRAM GUIDES X 5
BABY CARE BASICS FOR THE FORMULA-FEEDING MOTHER (49:00)
CHILDREN AND DIABETES (41:00)
COMMON CHILDHOOD ILLNESSES
NEW BORN ASSESSMENT
RESUSCITATION OF THE NEWBORN: TRACH CARE, HIGH FREQUENCY
JET VENTILATION, NICU
MEDICATION CHILDREN
PEDIATRIC MEDICATION ADMINISTRATION:
P042
ORAL MEDS
P041
PARENTAL MEDS
P043
PRINCIPLES AND CALCULATIONS
A002
PEDIATRIC ASSESSMENT:
D060 INFANTS AND TODDLERS
D061PRESCHOOL AND SCHOOL AGE
D062
THE ADOLESCENT
PHYSICAL ASSESSMENT OF A CHILD
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CLINICAL EVALUATION TOOLS
15
SOUTH PLAINS COLLEGE
ASSOCIATE DEGREE NURSING PROGRAM
CLINICAL EVALUATION TOOLS
Name: __________________________ Semester: _______________ Year: _______________
Midterm Clinical Grade: _______ Final Clinical Grade: ________ RNSG 1412 Grade: ________
Purpose
The Clinical Evaluation Tool will be utilized by the student and the instructor to evaluate the
student’s achievement of specified clinical performance objectives. The objectives must be
achieved during the clinical learning experience in order to fulfill the course. Actual clinical
experiences or, simulation experiences will be used to evaluate clinical performance objectives.
Objectives must be met according to the specified unit goals.
Meeting an objective includes:
1. Accurately describing the procedure/activity when indicated.
2. Performing the procedure/activity correctly in a reasonable amount of time.
Clinical Performance Rating Scale:
Clinical performance will be rated by the student and instructor on a scale as follows:
4 = Excellent- The student exceeds the expectations for the objective.
Demonstrates problem solving, critical thinking skills and shows initiative
in completing objective.
(Grade equivalent to an “A”)
3 = Good -
The student completes the objective without prompting from faculty.
(Grade equivalent to an “B”)
2 = Fair -
The student completes the objective but requires minimal or occasional
prompting. (Grade equivalent to a “C”)
1 = NI
The student is unable to complete objective without frequent assistance
and or prompting. The rating o this objective must improve to a 2 or
better in order to pass this course.
0 = Unsafe
The student did not meet this objective. The rating on this objective must
improve to a 2 or better in order to pass this course. Exception:
Depending on the nature of the problem, a 0 could be grounds for
immediate removal from clinical and referral to the director and/or the
Admissions Academic Standards Committee. (Refer to the policy
regarding unsafe clinical practice in the student handbook.)
P = Pass; F = Fail; NI = Needs Improvement; I = Incomplete at Midterm; NA = Not Applicable;
NO = No Opportunity
16
1.
The clinical evaluation tool will be based on the three roles of nursing and be constructed
utilizing the South Plains College Associate Degree Nursing Program Educational
Objectives.
2.
Each course will use the following level objectives.
Level I
RNSG 1513
RNSG 1144
RNSG 1105
RNSG 1160
RNSG 1115
Level II
RNSG 1441
RNSG 2460
Level II
RNSG 2307
RNSG 2260
RNSG 1115
Level II
RNSG 2213
Level III
RNSG 1210
RNSG 2261
Level III
RNSG 1413
RNSG 2462
Level III
RNSG 2414
RNSG 2461
3.
Additional criteria to measure each objective will be course specific and determined by
the course leader.
4.
A student must achieve a rating of 2, 3, or 4 for each of the level objectives within the
roles. (these are designated with capital letters under each role)
5.
Administration of medications must be performed accurately and safely to pass clinical.
Refer to the South Plains College student medication administration policy for further
information.
6.
The student is responsible for seeking out skills needed to meet the clinical performance
objectives on a continuous basis.
7.
The instructor will monitor the student's progress on an on going basis, and provide
comments regarding satisfactory or unsatisfactory completion of objectives.
8.
Individual student/instructor conferences will be arranged by appointment and held at
midterm, at the end of a course, and as needed to evaluate progress.
9.
It is the student's responsibility to meet with the instructor if he/she is having difficulty in
achieving the specified objectives.
10.
Final grade average on all assigned paperwork must be 77% to pass the course.
17
RNSG 2462
COURSE SPECIFIC CLINICAL EVALUATION TOOLS
CRITERIA AND INSTRUCTIONS
Please evaluate yourself by circling a number in the Student column. You may write comments
regarding why you gave yourself the score if you wish to in the Student Comments column. You
MUST complete the Student Comments column if it says to “Make a statement” regarding how
you met that objective. Please refer to the clinical performance rating scale for guidance in selfscoring.
A faculty member will also score how you met the objective and will make suggestions or
comments when deemed necessary in the Faculty comments column.
To pass the clinical course you must achieve the following:
1. Obtain a faculty score of 2 or better on the overall objectives (these are preceded by an
alphabetical letter).
2. Achieve a faculty score of 2 or better on the starred (*) objectives on the final evaluation
tool. Newborn assessment (starred objective) must be passed with a score of 2 or better (you
will be allowed two attempts to pass.)
4. Achieve a score of 2 or better on 77% of site tool unit scores.
5. Complete one evaluation on WebCT for each site you attend during clinical rotations.
6. Grade average must be 77% on assignments.
7. Turn in the completed MIDTERM evaluation when due and include the following:
a. Midterm Evaluation Tool
b. Completed self evaluation for the first half of the semester
c. All clinical site tools for the first half of the semester and nursing processes
d. Pediatric prep sheets (if applicable)
e. Completed computer program check off sheet with at least required programs initialed
by lab personal. (pages 11 and 12).
8. For your FINAL evaluation, turn in your completed responsibility folder and include:
a. Front sheet of the responsibility folder (page 10)
b. Computer check off sheet.
c. ALL clinical site tools for the entire semester.
d. Video and lab check off sheet (completed at the first of the semester)
e. All completed Pediatric Prep sheets
f. Midterm Clinical Evaluation Tool
g. Final Clinical Evaluation Tool
h. Complete your second student self evaluation statement for the last half of the
semester.
i. Graded nursing processes for the entire semester
18
Evaluation
RNSG 2462
SOUTH PLAINS COLLEGE
ASSOCIATE DEGREE NURSING PROGRAM
FACULTY CONFERENCE RECORD
Segment A Conference:
Comments
Date
Student
Clinical Facility
Clinical Instructor
Student Signature
Date
Segment B Conference:
Comments
Date
Student
Clinical Facility
Clinical Instructor
Student Signature
Date
19
Evaluation
RNSG 2462
SOUTH PLAINS COLLEGE
ASSOCIATE DEGREE NURSING PROGRAM
STUDENT'S SELF EVALUATION
Segment A Evaluation:
Student Signature
Date
Segment B Evaluation:
Student Signature
Date
20
RNSG 2462
Clinical Performance Objectives
MID-TERM CLINICAL EVALUATION TOOL
Student
Student Comments
Faculty
PROVIDER OF CARE
A. Integrate theoretical concepts with
nursing knowledge and skills to meet
the basic needs of childbearing and
childrearing clients, families and/or
groups in variety of settings.
1. Take client history using structured and 0 1 2 3 4
unstructured data collections tools to obtain
physical, psychosocial, spiritual, cultural,
familial, occupational, environmental
information, risk factors and client
resources.
* 2. Charts appropriately in clinical
01234
settings.
01234
3. Recognize that political, economic and 0 1 2 3 4
societal forces affect the health of clients.
01234
4. Completed Newborn Assessment
01234
01234
01234
01234
B. Integrate the five steps of the nursing
process into nursing practice.
01234
1. Designs and prioritizes nursing
01234
diagnoses based upon the analysis of client
needs.
2. Identify short and long term
01234
goals/outcomes, select interventions and
establish priorities for care in collaboration
with the client.
3. Implement a plan of care according to 0 1 2 3 4
the SPC nursing process format within legal
and ethical parameters in collaboration with
clients, families and other health care
professionals.
01234
01234
01234
Faculty Suggestions/Comments
21
RNSG 2462
Clinical Performance Objectives
MID-TERM CLINICAL EVALUATION TOOL
Student
C. Incorporate effective skills of
communication and collaboration with
clients, families, and/or groups in a
variety of setting.
1. Communicate plan of care to nurses
and other interdisciplinary health care team
members
2. Participates in discharge planning in
collaboration with the client, family and
health care team.
D. Formulate safe, cost effective
nursing care in collaboration with
members of the health care team using
critical thinking, problem solving, and
the nursing process in a variety of
settings through direct care,
assignment, or delegation of care.
*1. Promote a safe, effective environment
conducive to the optimal health and dignity
of the client.
*2. Demonstrates knowledge of all
medications patient is receiving.
*3 Completes procedures safely according
to the specific institutions' policy and
procedure manual, in a timely manner.
4. Evaluate, document, and report
responses to medications, treatments, and
procedures and communicate the same to
other health care professionals clearly and
accurately.
5. Collaborate with other health care
providers regarding treatments and
procedures.
6. Utilize therapeutic communications
skills when interacting with clients.
Student Comments.
Faculty
01234
01234
01234
01234
01234
01234
Make statement.
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
Faculty Comments/Suggestions
22
RNSG 2462
Clinical Performance Objectives
7. Identify priorities and make judgments
concerning the needs of multiple clients in
order to organize and manage their care.
8. Examine the use of the Delegation
Rules from the Texas Nurse Practice Act.
MID-TERM CLINICAL EVALUATION TOOL
Student
01234
Student Comments.
Faculty Faculty Comments/Suggestions
01234
01234
Make Statement.
01234
E. Integrate principles of teachinglearning in providing information to
clients, families and/or groups regarding
promotion, maintenance, and
restoration of health in the
childbearing/childrearing years.
1. Identify learning needs of clients
01234
related to health promotion, maintenance
and risk reduction.
2. Evaluate learning outcomes of the
01234
client receiving instruction.
3. Modify teaching methods to
accommodate client differences.
F. Evaluate clinical data, current
literature, and responses and outcomes
to therapeutic interventions to make
appropriate nursing practice decisions..
1. Analyze client data to compare
expected and achieved outcomes for client.
2. Modify plan of care and/or expected
outcomes.
3. Use critical thinking as a basis for
decision making in nursing practice.
4. Utilizes current literature to compare
client diagnostic studies with normal levels
and offers explanation and appropriate
nursing interventions for abnormal levels.
01234
01234
01234
01234
Make statement.
01234
01234
01234
01234
01234
01234
01234
01234
01234
Make statement.
01234
23
RNSG 2462
Clinical Performance Objectives
COORDINATOR OF CARE
A. Determine the function within the
organizational framework of various
health care settings.
1. Completes site tools with critical
thinking skills in a variety of settings.
B. Evaluate the effectiveness of
community resources in the delivery of
health care to clients, families, and/or
groups.
1. Assess the adequacy of the support
system of the client.
MID-TERM CLINICAL EVALUATION TOOL
Student
01234
Student Comments
Faculty Faculty Comments/Suggestions
01234
01234
01234
01234
01234
2. Advocate on behalf of the client with
01234
other members of the health team to
procure resources for client care.
C. Coordinate the health care team in
delivering care to clients, families or
groups.
1. Work with client and interdisciplinary
01234
health care team for planning health care
delivery to improve the quality of care
during childbearing and childrearing.
2. Promote effective coordination of client 0 1 2 3 4
centered health care.
01234
D. Coordinate appropriate referral
sources to meet the needs of clients,
families and/or groups.
1. Analyze potential referrals to
community agencies and health care
resources to provide continuity of care.
01234
01234
01234
01234
01234
01234
24
RNSG 2462
Clinical Performance Objectives
MID-TERM CLINICAL EVALUATION TOOL
Student
E. Utilize critical thinking and problem
solving skills in prioritizing the
management and coordination of all
aspects of care.
1. Identify and participate in activities to
improve health care delivery within the
clinical setting.
2. Implements cost-effective measures
while providing client care.
Student Comments
01234
01234
Faculty Faculty Comments/Suggestions
01234
01234
Make statement.
01234
MEMBER OF THE PROFESSION
A. Evaluate the responsibility for
professional and personal growth and
development.
1. Promote collegiality among fellow
students and among the health care team.
2. Evaluates personal participation in
conferences to promote learning of self and
others by sharing information and asking
questions.
3. Arrives to clinical rotations exhibiting
evidence of advanced preparation.
4. Serve as a positive role model for
peers and members of the health care
team.
*5. Personal appearance and professional
demeanor are appropriate for each
assigned unit.
*6. Arrives on time to clinicals ready to
assume patient care.
*7. Turns in assignments on OR before
due date.
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
25
RNSG 2462
Clinical Performance Objectives
MID-TERM CLINICAL EVALUATION TOOL
Student
B. Integrate ethical and legal
responsibility and accountability for
one's nursing practice.
1. Provide nursing care within limits of
the student's knowledge, education,
experience and ethical/legal standards of
care.
2. Prepares appropriately prior to
performing skills in clinical settings.
3. Submits completed clinical site tools
and responsibility folder weekly to clinical
instructors.
C. Integrate the actions of a health care
advocate to provide quality health care
for clients, families and/or groups..
1. Support the client's right of choice
even when these choice conflict with
values of the individual student.
2. Identify client's unmet needs from a
holistic perspective.
3. Functions as a health care advocate to
protect patient/family rights concerning
confidential information.
D. Evaluate one's own caring behavior
when interacting with clients, families
and member of the health care
profession.
1. Evaluate the learning needs of self,
peers, or others and intervene to assure
quality of care.
2. Provide holistic care that addresses
the needs of diverse individuals across the
child-bearing and child-rearing family.
3. Evaluates personal behaviors that
were effective and not effective.
4. Responds to instruction by exhibiting
change in behavior when needed.
Student Comments
Faculty Faculty Comments/Suggestions
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
Make statement.
01234
01234
01234
01234
01234
01234
01234
01234
Make statement.
01234
01234
26
RNSG 2462
FINAL CLINICAL EVALUATION TOOL
27
RNSG 2462
Clinical Performance Objectives
FINAL CLINICAL EVALUATION TOOL
Student
Student Comments
Faculty
PROVIDER OF CARE
A. Integrate theoretical concepts with
nursing knowledge and skills to meet
the basic needs of childbearing and
childrearing clients, families and/or
groups in a variety of settings.
1. Take client history using structured
and unstructured data collections tools to
obtain physical, psychosocial, spiritual,
cultural, familial, occupational,
environmental information, risk factors and
client resources.
*2. Charts appropriately in clinical
settings.
01234
01234
01234
01234
01234
3. Recognize that political, economic and 0 1 2 3 4
societal forces affect the health of clients.
01234
*4. Complete the Teaching Project or
article presentation.
01234
01234
B. Integrate the five steps of the
nursing process into nursing practice.
1. Designs and prioritizes nursing
diagnoses based upon the analysis of
client needs.
2. Identify short and long term
goals/outcomes, select interventions and
establish priorities for care in collaboration
with the client.
3. Implement a plan of care according to
the SPC nursing process format within
legal and ethical parameters in
collaboration with clients, families and
other health care professionals.
01234
01234
01234
01234
01234
01234
01234
Faculty Comments
28
RNSG 2462
Clinical Performance Objectives
*4. Complete one Obstetric and one
Pediatric Database.
FINAL CLINICAL EVALUATION TOOL
Student
01234
C. Incorporate effective skills of
communication and collaboration with
clients, families, and/or groups in a
variety of settings..
1. Communicate plan of care to nurses
01234
and other interdisciplinary health care team
members
2. Participates in discharge planning in
01234
collaboration with the client, family and
health care team.
D. Formulate safe, cost effective
nursing care in collaboration with
members of the health care team using
critical thinking, problem solving, and
the nursing process in a variety of
settings through direct care,
assignment, or delegation of care.
*1. Promote a safe, effective environment 0 1 2 3 4
conducive to the optimal health and dignity
of the client.
*2. Demonstrates knowledge of all
medications patient is receiving.
Student Comments
Faculty
01234
01234
01234
01234
01234
Make statement.
01234
01234
01234
*3. Completes procedures safely
01234
according to the specific institutions' policy
and procedure manual, in a timely manner.
4. Evaluate, document, and report
01234
responses to medications, treatments, and
procedures and communicate the same to
other health care professionals clearly and
accurately.
01234
01234
Faculty Comments
29
RNSG 2462
Clinical Performance Objectives
5. Collaborate with other health care
providers regarding treatments and
procedures.
6. Utilize therapeutic communications
skills when interacting with clients.
7. Identify priorities and make judgments
concerning the needs of multiple clients in
order to organize and manage their care.
8. Examine the use of the Delegation
Rules from the Texas Nurse Practice Act.
E. Integrate principles of teachinglearning in providing information to
clients, families and/or groups
regarding promotion, maintenance, and
restoration of health in the
childbearing/childrearing years..
1. Identify learning needs of clients
related to health promotion, maintenance
and risk reduction.
2. Collaborate with others to develop and
modify individualized teaching plans based
upon developmental and health care
learning needs.
3. Evaluate learning outcomes of the
client receiving instruction.
4. Modify teaching methods to
accommodate client differences.
FINAL CLINICAL EVALUATION TOOL
Student
01234
Student Comments
Faculty
01234
01234
01234
01234
01234
01234
Make statement.
01234
01234
01234
01234
01234
01234
01234
01234
01234
Make Statement
01234
Faculty Comments
30
RNSG 2462
Clinical Performance Objectives
FINAL CLINICAL EVALUATION TOOL
Student
F. Evaluate clinical data, current
literature, and responses and outcomes
to therapeutic interventions to make
appropriate nursing practice decisions.
1. Analyze client data to compare
01234
expected and achieved outcomes for
client.
2. Modify plan of care and/or expected
01234
outcomes.
Student Comments
Faculty
01234
01234
01234
3. Use critical thinking as a basis for
decision making in nursing practice.
01234
01234
4. Read and discuss relevant, current
nursing practice journal articles and apply
to practice.
5. Utilizes current literature to compare
client diagnostic studies with normal levels
and offers explanation and appropriate
nursing interventions for abnormal levels.
01234
01234
COORDINATOR OF CARE
A. Determine the function within the
organizational framework of various
healthcare settings.
1. Completes site tools with critical
thinking skills in a variety of settings.
*2, Scored a 2 or better on 77% or more
of the site tools for this semester.
B. Evaluate the effectiveness of
community resources in the delivery of
health care to clients, families, and/or
groups.
1. Assess the adequacy of the support
system of the client.
2. Advocate on behalf of the client with
other members of the health team to
procure resources for client care.
01234
Make statement.
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
Faculty Comments
31
RNSG 2462
Clinical Performance Objectives
FINAL CLINICAL EVALUATION TOOL
Student
C. Coordinate the health care team in
delivering care to clients, families or
groups.
1. Work with client and interdisciplinary
health care team for planning health care
delivery to improve the quality of care
during childbearing and childrearing.
2. Promote effective coordination of
client centered health care.
D. Coordinate appropriate referral
sources to meet the needs of clients,
families and/or groups.
1. Analyze potential referrals to
community agencies and health care
resources to provide continuity of care.
E. Utilize critical thinking and problem
solving skills in prioritizing the
management and coordination of all
aspects of care.
1. Identify and participate in activities to
improve health care delivery within the
clinical setting.
2. Implements cost-effective measures
while providing client care.
MEMBER OF THE PROFESSION
A. Evaluate responsibility for
professional and personal growth and
development.
1. Promote collegiality among fellow
students and among the health care team.
2. Evaluates personal participation in
conferences to promote learning of self
and others by sharing information and
asking questions.
Student Comments
Faculty
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
Make statement.
01234
01234
01234
01234
01234
01234
Faculty Comments
32
RNSG 2462
Clinical Performance Objectives
3. Arrives to clinical rotations exhibiting
evidence of advanced preparation.
4. Serve as a positive role model for
peers and members of the health care
team.
*5. Personal appearance and professional
demeanor are appropriate for each
assigned unit.
*6. Arrives on time to clinicals ready to
assume patient care.
B. Integrate ethical and legal
responsibility and accountability for
one's nursing practice.
1. Provide nursing care within limits of
the student's nursing knowledge,
education, experience and ethical/legal
standards of care.
2. Prepares appropriately prior to
performing skills.
*3. Submits completed clinical site tools
and assignments on or before due date.
FINAL CLINICAL EVALUATION TOOL
Student
01234
Student Comments
Faculty
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
C. Integrate the actions of a health care
advocate to provide quality health care
for clients, families and/or groups.
1. Support the client's right of choice
01234
even when these choice conflict with
values of the individual student.
2. Identify client's unmet needs from a
01234
holistic perspective.
3. Functions as a health care advocate to 0 1 2 3 4
protect patient/family rights concerning
confidential information.
01234
01234
01234
Make Statement
01234
Faculty Comments
33
RNSG 2462
Clinical Performance Objective
FINAL CLINICAL EVALUATION TOOL
Student
D. Evaluate one's own caring behavior
when interacting with clients, families
and member of the health care
profession.
1. Evaluate the learning needs of self,
peers, or others and intervene to assure
quality of care.
2. Provide holistic care that addresses
the needs of diverse individuals across the
child-bearing and child-rearing family.
3. Evaluates personal behaviors that
were effective and not effective.
4. Responds to instruction by exhibiting
change in behavior when needed.
Student Comments
Faculty
01234
01234
01234
01234
01234
01234
01234
Make statement.
01234
01234
Faculty Comments
34
UNIT SPECIFIC CLINICAL REQUIREMENTS
(Student must complete & submit weekly site tools through Web CT
by 0900 Monday following the clinical rotations)
35
NEONATAL INTENSIVE CARE (NICU)
Clinical Preparation Requirements
You will not pick up a patient assignment the day before this rotation--you will be assigned to a
nurse when you arrive in the NICU and will assist that TPCN as they deem appropriate.
Did you do each of these BEFORE going to NICU?
_____Review the clinical site tool objectives and “site tool hints” found on WebCT
_____Read the appropriate chapters in the Pediatrics textbook (Suggest reading chapters on
pre-maturity and high risk newborn)
_____Read UMC orientation packet for NICU
Bring these with you to NICU:
_____Print a copy of the NICU site tool on WebCT to review and bring with you to gather
needed information
36
LABOR AND DELIVERY
Clinical Preparation Requirements
You will not pick up a patient the day before clinicals-you will be assigned a patient when you
arrive at the labor and delivery area. You will primarily be doing observational work and
helping the TPCN. You must complete a student chart for one patient daily that you are
assigned.
Did you do each of these BEFORE going to labor and delivery?
_____ Review the labor and delivery site tool objectives and site tool hints found on WebCT
_____ Complete the drug cards for labor and delivery/antepartum -THESE MUST BE
HANDWRITTEN--TYPED CARDS WILL NOT BE ACCEPTED. (Suggestion: look in
your OB textbook for some of this information.)
_____ Complete the “Labor and Delivery Study Guide” found in the syllabus. (Does not need to
be turned in for grade.)
_____ Review “Stages of Labor Chart” and “Intrapartum Electronic Fetal Monitoring Study
Guides” found in your syllabus.
_____ Read appropriate chapters in your OB textbook and the Lamaze Parents Magazine.
_____ Review “Stages of Labor” assignment so that you are aware of the information you will
need to gather to complete this assignment.
_____ Read the UMC “Perinatal Area” orientation packet regarding labor and delivery.
_____ Review OB student charting sheets and the example of how to complete the charting
sheet.
_____ Review video skills DVD. (optional)
Bring these things with you to Labor and Delivery clinical rotations:
_____ Print a copy of the labor and delivery site tool on WebCT to bring with you to gather
needed information.
_____ Completed labor and delivery/antepartum drug cards.
_____ Student charting sheets (bring several with you-you must complete one chart per day and
turn them in with your completed weekly site tool.
_____ “Stages of Labor” to gather patient information.
_____ The last week of Labor & Delivery rotations, bring Nursing Process sheets (1 diagnosis
must be complete turned in on Tuesday following the rotation.) See nursing process
guidelines for more information (p. 181)
37
RNSG 2462-CLINICAL DRUG CARDS
ANTEPARTUM/LABOR AND DELIVERY
THESE MUST BE HANDWRITTEN-NO TYPED CARDS WILL BE ACCEPTED.
Complete drug cards for these medications using the Antepartum/Labor & Delivery drug card forms in the
syllabus. The faculty will critique them at the clinical setting. Be prepared to discuss the appropriate drugs
ordered for your patient in the clinical setting. Look in your OB textbook for some of the information.
Betamethasone
Bicitra
Calcium Gluconate
Cervidil
Cytotec
Demerol
Fentanyl (Sublimaze)
Hemabate
Indomethacin
Ropivacaine
Methergine
Magnesium Sulfate
Pitocin
Phenergan
Procardia
Stadol
Terbutaline (Brethine)
Vistaril
38
ANTEPARTUM/LABOR & DELIVERY DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY/ROUTE______________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
OB USES__________________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
ANTEPARTUM/LABOR & DELIVERY DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY/ROUTE_____________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
OB USES__________________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
39
ANTEPARTUM/LABOR & DELIVERY DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY/ROUTE_____________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
OB USES__________________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
ANTEPARTUM/LABOR & DELIVERY DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY/ROUTE_____________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
OB USES__________________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
40
ANTEPARTUM/LABOR & DELIVERY DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY/ROUTE_____________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
OB USES__________________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
ANTEPARTUM/LABOR & DELIVERY DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY/ROUTE_____________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
OB USES__________________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
41
ANTEPARTUM/LABOR & DELIVERY DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY/ROUTE_____________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
OB USES__________________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
ANTEPARTUM/LABOR & DELIVERY DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY/ROUTE_____________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
OB USES__________________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
42
ANTEPARTUM/LABOR & DELIVERY DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY/ROUTE_____________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
OB USES__________________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
ANTEPARTUM/LABOR & DELIVERY DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY/ROUTE_____________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
OB USES__________________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
43
ANTEPARTUM/LABOR & DELIVERY DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY/ROUTE______________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
OB USES__________________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
ANTEPARTUM/LABOR & DELIVERY DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY/ROUTE_____________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
OB USES__________________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
44
ANTEPARTUM/LABOR & DELIVERY DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY/ROUTE______________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
OB USES__________________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
ANTEPARTUM/LABOR & DELIVERY DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY/ROUTE______________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
OB USES__________________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
45
ANTEPARTUM/LABOR & DELIVERY DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY/ROUTE______________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
OB USES__________________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
ANTEPARTUM/LABOR & DELIVERY DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY/ROUTE______________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
OB USES__________________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
46
ANTEPARTUM/LABOR & DELIVERY DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY/ROUTE______________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
OB USES__________________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
ANTEPARTUM/LABOR & DELIVERY DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY/ROUTE_____________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
OB USES__________________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
47
RNSG 2462 Labor and Delivery Student Charting Sheet
Date: ______________ Student’s Name: ___________________
G __ T __ P __ AB __ L __ Membranes: ___AROM____SROM
EGA ______________
____Clear ____ Meconium
Maternal Assessment
V.S.
Time
V.S
Time
____________________
____________________
____________________
____________________
_____
_____
_____
_____
Vaginal Exams
Time
**Include Dilation ______
Effacement &
Station in the
____
____
____
____
____
____
____
____
_________________
_________________
_________________
_________________
Results
Time
___________
______ ___________
______ ___________
______ ___________
Results space
Contraction Assessment
Time Mode Freq.
Int.
____
____
____
____
____
____
____
____
_____
_____
_____
_____
____
____
____
____
____
____
____
____
Dur.
Results
______ ___________
______ ___________
______ ___________
______ ___________
Fetal Assessment
Rest
Mode
Base
Tone
Line
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____
____
____
____
____
____
____
____
Var.
Accels Decels
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
Mode: I (Internal monitor) E (External monitor)
Freq: Contraction frequency
Int: Intensity of contractions=M (mild) Mod. (moderate) S (strong)
Dur.: Duration range of the contraction
Rest Tone: Resting tone of uterus = S (soft) T (tense)
Baseline: FHR baseline Var.: Variability=A (absent) M (minimal: <5bpm) Mod
(moderate: 6-25 bpm) Ma (marked: >25 bpm)
Accels: FHR accelerations range (10x10; 15x15)
Decels:N (none) E (early decels) V (variable decels) L (late decels)
Medications
Pitocin Y N beginning dose ________ ending dose _________
MgSO4 Y N dose ________
Epidural Y N
Analgesia:Med._________dose_____route_____times____
_____
48
RNSG 2462 Labor and Delivery Student Charting Sheet
Date: ______________ Student’s Name: ___________________
G __ T __ P __ AB __ L __ Membranes: ___AROM____SROM
EGA ______________
____Clear ____ Meconium
Maternal Assessment
V.S.
Time
V.S
Time
____________________
____________________
____________________
____________________
_____
_____
_____
_____
Vaginal Exams
Time
**Include Dilation ______
Effacement &
Station in the
____
____
____
____
____
____
____
____
_________________
_________________
_________________
_________________
Results
Time
___________
______ ___________
______ ___________
______ ___________
Results space
Contraction Assessment
Time Mode Freq.
Int.
____
____
____
____
____
____
____
____
_____
_____
_____
_____
____
____
____
____
____
____
____
____
Dur.
Results
______ ___________
______ ___________
______ ___________
______ ___________
Fetal Assessment
Rest
Mode
Base
Tone
Line
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____
____
____
____
____
____
____
____
Var.
Accels Decels
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
Mode: I (Internal monitor) E (External monitor)
Freq: Contraction frequency
Int: Intensity of contractions=M (mild) Mod. (moderate) S (strong)
Dur.: Duration range of the contraction
Rest Tone: Resting tone of uterus = S (soft) T (tense)
Baseline: FHR baseline Var.: Variability=A (absent) M (minimal: <5bpm) Mod
(moderate: 6-25 bpm) Ma (marked: >25 bpm)
Accels: FHR accelerations range
Decels:N (none) E (early decels) V (variable decels) L (late decels)
Medications
Pitocin Y N beginning dose ________ ending dose _________
MgSO4 Y N dose ________
Epidural Y N
Analgesia:Med._________dose_____route_____times____
_____
49
RNSG 2462 Labor and Delivery Student Charting Sheet
Date: ______________ Student’s Name: ___________________
G __ T __ P __ AB __ L __ Membranes: ___AROM____SROM
EGA ______________
____Clear ____ Meconium
Maternal Assessment
V.S.
Time
V.S
Time
____________________
____________________
____________________
____________________
_____
_____
_____
_____
Vaginal Exams
Time
**Include Dilation ______
Effacement &
Station in the
____
____
____
____
____
____
____
____
_________________
_________________
_________________
_________________
Results
Time
___________
______ ___________
______ ___________
______ ___________
Results space
Contraction Assessment
Time Mode Freq.
Int.
____
____
____
____
____
____
____
____
_____
_____
_____
_____
____
____
____
____
____
____
____
____
Dur.
Results
______ ___________
______ ___________
______ ___________
______ ___________
Fetal Assessment
Rest
Mode
Base
Tone
Line
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____
____
____
____
____
____
____
____
Var.
Accels Decels
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
Mode: I (Internal monitor) E (External monitor)
Freq: Contraction frequency
Int: Intensity of contractions=M (mild) Mod. (moderate) S (strong)
Dur.: Duration range of the contraction
Rest Tone: Resting tone of uterus = S (soft) T (tense)
Baseline: FHR baseline Var.: Variability=A (absent) M (minimal: <5bpm) Mod
(moderate: 6-25 bpm) Ma (marked: >25 bpm)
Accels: FHR accelerations range
Decels:N (none) E (early decels) V (variable decels) L (late decels)
Medications
Pitocin Y N beginning dose ________ ending dose _________
MgSO4 Y N dose ________
Epidural Y N
Analgesia:Med._________dose_____route_____times____
_____
50
RNSG 2462 Labor and Delivery Student Charting Sheet
Date: ______________ Student’s Name: ___________________
G __ T __ P __ AB __ L __ Membranes: ___AROM____SROM
EGA ______________
____Clear ____ Meconium
Maternal Assessment
V.S.
Time
V.S
Time
____________________
____________________
____________________
____________________
_____
_____
_____
_____
Vaginal Exams
Time
**Include Dilation ______
Effacement &
Station in the
____
____
____
____
____
____
____
____
_________________
_________________
_________________
_________________
Results
Time
___________
______ ___________
______ ___________
______ ___________
Results space
Contraction Assessment
Time Mode Freq.
Int.
____
____
____
____
____
____
____
____
_____
_____
_____
_____
____
____
____
____
____
____
____
____
Dur.
Results
______ ___________
______ ___________
______ ___________
______ ___________
Fetal Assessment
Rest
Mode
Base
Tone
Line
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____
____
____
____
____
____
____
____
Var.
Accels Decels
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
Mode: I (Internal monitor) E (External monitor)
Freq: Contraction frequency
Int: Intensity of contractions=M (mild) Mod. (moderate) S (strong)
Dur.: Duration range of the contraction
Rest Tone: Resting tone of uterus = S (soft) T (tense)
Baseline: FHR baseline Var.: Variability=A (absent) M (minimal: <5bpm) Mod
(moderate: 6-25 bpm) Ma (marked: >25 bpm)
Accels: FHR accelerations range
Decels:N (none) E (early decels) V (variable decels) L (late decels)
Medications
Pitocin Y N beginning dose ________ ending dose _________
MgSO4 Y N dose ________
Epidural Y N
Analgesia:Med._________dose_____route_____times____
_____
51
RNSG 2462 Labor and Delivery Student Charting Sheet
Date: ______________ Student’s Name: ___________________
G __ T __ P __ AB __ L __ Membranes: ___AROM____SROM
EGA ______________
____Clear ____ Meconium
Maternal Assessment
V.S.
Time
V.S
Time
____________________
____________________
____________________
____________________
_____
_____
_____
_____
Vaginal Exams
Time
**Include Dilation ______
Effacement &
Station in the
____
____
____
____
____
____
____
____
_________________
_________________
_________________
_________________
Results
Time
___________
______ ___________
______ ___________
______ ___________
Results space
Contraction Assessment
Time Mode Freq.
Int.
____
____
____
____
____
____
____
____
_____
_____
_____
_____
____
____
____
____
____
____
____
____
Dur.
Results
______ ___________
______ ___________
______ ___________
______ ___________
Fetal Assessment
Rest
Mode
Base
Tone
Line
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____
____
____
____
____
____
____
____
Var.
Accels Decels
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
Mode: I (Internal monitor) E (External monitor)
Freq: Contraction frequency
Int: Intensity of contractions=M (mild) Mod. (moderate) S (strong)
Dur.: Duration range of the contraction
Rest Tone: Resting tone of uterus = S (soft) T (tense)
Baseline: FHR baseline Var.: Variability=A (absent) M (minimal: <5bpm) Mod
(moderate: 6-25 bpm) Ma (marked: >25 bpm)
Accels: FHR accelerations range
Decels:N (none) E (early decels) V (variable decels) L (late decels)
Medications
Pitocin Y N beginning dose ________ ending dose _________
MgSO4 Y N dose ________
Epidural Y N
Analgesia:Med._________dose_____route_____times____
_____
52
RNSG 2462 Labor and Delivery Student Charting Sheet
Date: ______________ Student’s Name: ___________________
G __ T __ P __ AB __ L __ Membranes: ___AROM____SROM
EGA ______________
____Clear ____ Meconium
Maternal Assessment
V.S.
Time
V.S
Time
____________________
____________________
____________________
____________________
_____
_____
_____
_____
Vaginal Exams
Time
**Include Dilation ______
Effacement &
Station in the
____
____
____
____
____
____
____
____
_________________
_________________
_________________
_________________
Results
Time
___________
______ ___________
______ ___________
______ ___________
Results space
Contraction Assessment
Time Mode Freq.
Int.
____
____
____
____
____
____
____
____
_____
_____
_____
_____
____
____
____
____
____
____
____
____
Dur.
Results
______ ___________
______ ___________
______ ___________
______ ___________
Fetal Assessment
Rest
Mode
Base
Tone
Line
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____
____
____
____
____
____
____
____
Var.
Accels Decels
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
Mode: I (Internal monitor) E (External monitor)
Freq: Contraction frequency
Int: Intensity of contractions=M (mild) Mod. (moderate) S (strong)
Dur.: Duration range of the contraction
Rest Tone: Resting tone of uterus = S (soft) T (tense)
Baseline: FHR baseline Var.: Variability=A (absent) M (minimal: <5bpm) Mod
(moderate: 6-25 bpm) Ma (marked: >25 bpm)
Accels: FHR accelerations range
Decels:N (none) E (early decels) V (variable decels) L (late decels)
Medications
Pitocin Y N beginning dose ________ ending dose _________
MgSO4 Y N dose ________
Epidural Y N
Analgesia:Med._________dose_____route_____times____
_____
53
RNSG 2462 Labor and Delivery Student Charting Sheet
Date: ______________ Student’s Name: ___________________
G __ T __ P __ AB __ L __ Membranes: ___AROM____SROM
EGA ______________
____Clear ____ Meconium
Maternal Assessment
V.S.
Time
V.S
Time
____________________
____________________
____________________
____________________
_____
_____
_____
_____
Vaginal Exams
Time
**Include Dilation ______
Effacement &
Station in the
____
____
____
____
____
____
____
____
_________________
_________________
_________________
_________________
Results
Time
___________
______ ___________
______ ___________
______ ___________
Results space
Contraction Assessment
Time Mode Freq.
Int.
____
____
____
____
____
____
____
____
_____
_____
_____
_____
____
____
____
____
____
____
____
____
Dur.
Results
______ ___________
______ ___________
______ ___________
______ ___________
Fetal Assessment
Rest
Mode
Base
Tone
Line
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____
____
____
____
____
____
____
____
Var.
Accels Decels
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
Mode: I (Internal monitor) E (External monitor)
Freq: Contraction frequency
Int: Intensity of contractions=M (mild) Mod. (moderate) S (strong)
Dur.: Duration range of the contraction
Rest Tone: Resting tone of uterus = S (soft) T (tense)
Baseline: FHR baseline Var.: Variability=A (absent) M (minimal: <5bpm) Mod
(moderate: 6-25 bpm) Ma (marked: >25 bpm)
Accels: FHR accelerations range
Decels:N (none) E (early decels) V (variable decels) L (late decels)
Medications
Pitocin Y N beginning dose ________ ending dose _________
MgSO4 Y N dose ________
Epidural Y N
Analgesia:Med._________dose_____route_____times____
_____
54
RNSG 2462 Labor and Delivery Student Charting Sheet
Date: ______________ Student’s Name: ___________________
G __ T __ P __ AB __ L __ Membranes: ___AROM____SROM
EGA ______________
____Clear ____ Meconium
Maternal Assessment
V.S.
Time
V.S
Time
____________________
____________________
____________________
____________________
_____
_____
_____
_____
Vaginal Exams
Time
**Include Dilation ______
Effacement &
Station in the
____
____
____
____
____
____
____
____
_________________
_________________
_________________
_________________
Results
Time
___________
______ ___________
______ ___________
______ ___________
Results space
Contraction Assessment
Time Mode Freq.
Int.
____
____
____
____
____
____
____
____
_____
_____
_____
_____
____
____
____
____
____
____
____
____
Dur.
Results
______ ___________
______ ___________
______ ___________
______ ___________
Fetal Assessment
Rest
Mode
Base
Tone
Line
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____
____
____
____
____
____
____
____
Var.
Accels Decels
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
Mode: I (Internal monitor) E (External monitor)
Freq: Contraction frequency
Int: Intensity of contractions=M (mild) Mod. (moderate) S (strong)
Dur.: Duration range of the contraction
Rest Tone: Resting tone of uterus = S (soft) T (tense)
Baseline: FHR baseline Var.: Variability=A (absent) M (minimal: <5bpm) Mod
(moderate: 6-25 bpm) Ma (marked: >25 bpm)
Accels: FHR accelerations range
Decels:N (none) E (early decels) V (variable decels) L (late decels)
Medications
Pitocin Y N beginning dose ________ ending dose _________
MgSO4 Y N dose ________
Epidural Y N
Analgesia:Med._________dose_____route_____times____
_____
55
RNSG 2462 Labor and Delivery Student Charting Sheet
Date: ______________ Student’s Name: ___________________
G __ T __ P __ AB __ L __ Membranes: ___AROM____SROM
EGA ______________
____Clear ____ Meconium
Maternal Assessment
V.S.
Time
V.S
Time
____________________
____________________
____________________
____________________
_____
_____
_____
_____
Vaginal Exams
Time
**Include Dilation ______
Effacement &
Station in the
____
____
____
____
____
____
____
____
_________________
_________________
_________________
_________________
Results
Time
___________
______ ___________
______ ___________
______ ___________
Results space
Contraction Assessment
Time Mode Freq.
Int.
____
____
____
____
____
____
____
____
_____
_____
_____
_____
____
____
____
____
____
____
____
____
Dur.
Results
______ ___________
______ ___________
______ ___________
______ ___________
Fetal Assessment
Rest
Mode
Base
Tone
Line
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____
____
____
____
____
____
____
____
Var.
Accels Decels
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
Mode: I (Internal monitor) E (External monitor)
Freq: Contraction frequency
Int: Intensity of contractions=M (mild) Mod. (moderate) S (strong)
Dur.: Duration range of the contraction
Rest Tone: Resting tone of uterus = S (soft) T (tense)
Baseline: FHR baseline Var.: Variability=A (absent) M (minimal: <5bpm) Mod
(moderate: 6-25 bpm) Ma (marked: >25 bpm)
Accels: FHR accelerations range
Decels:N (none) E (early decels) V (variable decels) L (late decels)
Medications
Pitocin Y N beginning dose ________ ending dose _________
MgSO4 Y N dose ________
Epidural Y N
Analgesia:Med._________dose_____route_____times____
_____
56
RNSG 2462 Labor and Delivery Student Charting Sheet
Date: ______________ Student’s Name: ___________________
G __ T __ P __ AB __ L __ Membranes: ___AROM____SROM
EGA ______________
____Clear ____ Meconium
Maternal Assessment
V.S.
Time
V.S
Time
____________________
____________________
____________________
____________________
_____
_____
_____
_____
Vaginal Exams
Time
**Include Dilation ______
Effacement &
Station in the
____
____
____
____
____
____
____
____
_________________
_________________
_________________
_________________
Results
Time
___________
______ ___________
______ ___________
______ ___________
Results space
Contraction Assessment
Time Mode Freq.
Int.
____
____
____
____
____
____
____
____
_____
_____
_____
_____
____
____
____
____
____
____
____
____
Dur.
Results
______ ___________
______ ___________
______ ___________
______ ___________
Fetal Assessment
Rest
Mode
Base
Tone
Line
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____
____
____
____
____
____
____
____
Var.
Accels Decels
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
____ ____ ____ _____
Mode: I (Internal monitor) E (External monitor)
Freq: Contraction frequency
Int: Intensity of contractions=M (mild) Mod. (moderate) S (strong)
Dur.: Duration range of the contraction
Rest Tone: Resting tone of uterus = S (soft) T (tense)
Baseline: FHR baseline Var.: Variability=A (absent) M (minimal: <5bpm) Mod
(moderate: 6-25 bpm) Ma (marked: >25 bpm)
Accels: FHR accelerations range
Decels:N (none) E (early decels) V (variable decels) L (late decels)
Medications
Pitocin Y N beginning dose ________ ending dose _________
MgSO4 Y N dose ________
Epidural Y N
Analgesia:Med._________dose_____route_____times____
_____
57
SOUTH PLAINS COLLEGE ADNP
NURSING PROCESS
Client’s Initials __________
Diagnosis ______________
Age _______ RM ________
ANALYSIS
Problem/Nursing
Diagnosis
Student ___________________
Date _____________________
Instructor _________________
PLAN
Goal Statements with
Outcome Criteria
IMPLEMENTATION
Nursing Orders
Scientific Rationale
EVALUATION
Evaluative Outcome
Criteria
58
SOUTH PLAINS COLLEGE ADNP
NURSING PROCESS
Client’s Initials __________
Diagnosis ______________
Age _______ RM ________
ANALYSIS
Problem/Nursing
Diagnosis
Student ___________________
Date _____________________
Instructor _________________
PLAN
Goal Statements with
Outcome Criteria
IMPLEMENTATION
Nursing Orders
Scientific Rationale
EVALUATION
Evaluative Outcome
Criteria
59
SOUTH PLAINS COLLEGE ADNP
NURSING PROCESS
Client’s Initials __________
Diagnosis ______________
Age _______ RM ________
ANALYSIS
Problem/Nursing
Diagnosis
Student ___________________
Date _____________________
Instructor _________________
PLAN
Goal Statements with
Outcome Criteria
IMPLEMENTATION
Nursing Orders
Scientific Rationale
EVALUATION
Evaluative Outcome
Criteria
60
SOUTH PLAINS COLLEGE ADNP
NURSING PROCESS
Client’s Initials __________
Diagnosis ______________
Age _______ RM ________
ANALYSIS
Problem/Nursing
Diagnosis
Student ___________________
Date _____________________
Instructor _________________
PLAN
Goal Statements with
Outcome Criteria
IMPLEMENTATION
Nursing Orders
Scientific Rationale
EVALUATION
Evaluative Outcome
Criteria
61
SOUTH PLAINS COLLEGE ADNP
NURSING PROCESS
Client’s Initials __________
Diagnosis ______________
Age _______ RM ________
ANALYSIS
Problem/Nursing
Diagnosis
Student ___________________
Date _____________________
Instructor _________________
PLAN
Goal Statements with
Outcome Criteria
IMPLEMENTATION
Nursing Orders
Scientific Rationale
EVALUATION
Evaluative Outcome
Criteria
62
SOUTH PLAINS COLLEGE ADNP
NURSING PROCESS
Client’s Initials __________
Diagnosis ______________
Age _______ RM ________
ANALYSIS
Problem/Nursing
Diagnosis
Student ___________________
Date _____________________
Instructor _________________
PLAN
Goal Statements with
Outcome Criteria
IMPLEMENTATION
Nursing Orders
Scientific Rationale
EVALUATION
Evaluative Outcome
Criteria
63
Appendix I/Labor & Delivery Study Guide
RNSG 2462
SOUTH PLAINS COLLEGE
ASSOCIATE DEGREE NURSING PROGRAM
LABOR AND DELIVERY STUDY GUIDE
*This may be handwritten or typed. If you type only the answers, please attach them to this
study guide. You are expected to do your own work on this study guide.
Please put the page number and source by each answer.
1. List the differences between true and false labor including signs and symptoms of true
labor in detail.
2. What are the signs and symptoms of approaching labor? Discuss in detail.
*3. Identify the (4) stages of labor including patient behaviors in each stage and nursing
responsibilities. Be sure and indicate stages of labor by what physical signs and
symptoms they begin with and end with. (use the LPM and textbook for this question)
4. List the types of anesthesia and analgesia used in labor and delivery and discuss how
they might affect the mother and her infant.
5. Discuss the role of a support person and how their absence and presence affects the
laboring mother.
6. Define the following Fetal Monitoring terms:
a. Baseline variability b. Minimal variability c No variability d. Early decelerations e. Late decelerations f. Variable decelerations g. Bradycardia (fetal) h. Trachycardia (fetal) i. NST j. CST __________________________________________
*Note: Please use your text and the Lamaze Parents Magazine for this question.
64
Appendix J/Stage of Labor
RNSG 2462
SOUTH PLAINS COLLEGE
ASSOCIATE DEGREE NURSING PROGRAM
STAGES OF LABOR CHART
Stage One - The Dilatation Stage
A Guide for Supporting Mothers in Labor
Stage One--The Dilatation stage (This period begins with the onset of true labor contractions and
ends with complete dilatation of the cervix (2-16 or more hour's duration).
I. Latent or three phases of the first stage.
EARLY ACTIVE PHASE--2 cm. to 4 cm. cervical dilatation.
CHARACTERISTICS
Uterine contractions may be mild (25-30 seconds), may follow a regular pattern (every 15-20
minutes) and may be accompanied by:
Abdominal cramps
Backache
Rupture of membranes
Show (blood-tinged mucoid vaginal discharge)
HOW THE MOTHER MAY FEEL
Excited. She may also feel:
A sense of anticipation.
A sense of relief.
Happy.
Some apprehension.
Reassured, if she talked with her doctor before coming to the hospital.
WHAT THE NURSE MAY DO TO SUPPORT THE MOTHER
A. Complete admission requirement as quickly as possible, adapting procedures to
mother's tolerance.
65
Appendix J/Stages of Labor
RNSG 2462
Stage One (continued)
B. When admission procedures are completed, if appropriate:
1. Let husband (if waiting) know how she seems and that he may join her.
2. Encourage the mother:
a. to divert herself with activities of interest to her.
b. to breathe deeply and slowly with contractions; if her back aches, to
combine rocking with slow deep breathing.
3. Help mother (and father, if present) to understand the labor process, what to
expect and how to promote the mother's comfort. (Not all have attended
childbirth classes)
4. Let the father (and the mother) listen to the fetal heart.
5. Instruct the father in:
a. How to time contractions.
b. How to rub the mother's back.
II. Active--4 cm. to 8 cm. cervical dilatation.
CHARACTERISTICS
Uterine contractions become stronger, longer (40-45 seconds), more frequent (every 5-7
minutes) and may be accompanied by pain.
HOW THE MOTHER MAY FEEL
Apprehensive. She may also feel:
A growing seriousness.
Ill-defined doubts and fears.
Desire for companionship.
Uncertain if she can cope with contractions.
WHAT THE NURSE MAY DO TO SUPPORT THE MOTHER
A. Encourage mother to:
1. Utilize breathing and relaxation techniques during contractions and
examinations.
2. Assume comfortable position on back (with hip wedge) or on side with each
contraction and examinations.
3. Try to relax between contractions.
66
Appendix J/Stages of Labor
RNSG 2462
Stage One (continued)
B. When appropriate:
1. Check fetal heart and blood pressure; if normal let mother (and father, if
present) know.
2. Apply cool; damp cloth to mother's face.
3. Moisten mother's lips or offer her ice chips.
4. Rub small of her back, or encourage father (if present) to rub it.
5. Apply warm "hot-water bottle" to mother's abdomen or to her back. Ice
works sometimes, also.
6. Commend mother for effort she is making.
7. Change pad on which mother is lying.
8. Encourage mother to void q l degree.
9. Consult doctor about mother's need for medication.
10. Keep mother (and father, if present) informed of her progress.
III.
Transition Phase---8 cm. to 10 cm. cervical dilatation.
CHARACTERISTICS
Uterine contractions may become stronger, longer (50-60 seconds); more frequent (every 1-2
minutes) and may be accompanied by:
Amnesia between contractions.
Cramp in legs.
Generalized discomfort.
Hiccoughing.
Irritable abdomen.
Marked restlessness.
Nausea and possible vomiting.
Pain.
Perspiration on upper lip and forehead.
Profuse, dark, heavy show.
Pulling or stretching sensation deep in pelvis.
Rupture of membranes.
Severe low backache.
Shaking of legs.
Emission of unexpected belch.
67
Appendix J/Stages of Labor
RNSG 2462
Stage One (continued)
HOW THE MOTHER MAY FEEL
Increasingly apprehensive. She may also feel:
Bewildered by intensity of contractions.
Irritable and unwilling to be touched.
Frustrated and unable to cope with contractions if left alone.
Eager to be "put to sleep".
Unable to comprehend directions readily.
WHAT THE NURSE MAY DO TO SUPPORT THE MOTHER
A. Encourage mother to:
1. relax as much as possible
2. try, with each contraction:
a. to do costal breathing slowly; or
b. to breathe shallowly, followed by pant-pant-blow pattern of breathing.
3. keep in mind that contractions have reached maximum strength and that relief
will soon come with pushing.
B. When appropriate
1. apply firm pressure to small of mother's back; or encourage father (if present) to
do so.
2. check fetal heart and blood pressure; if normal let mother and father (if present)
know.
3. check mother's perineum for evidence of increased show, rupture of membranes,
appearance of caput.
4. keep mother and father (if present) informed of her progress.
5. consult doctor about mother's need for medication.
6. encourage mother to void.
68
Appendix J/Stages of Labor
RNSG 2462
Stage Two - The Expulsive Stage
The period begins with the complete dilatation of the cervix and ends with the birth of the baby
(2-60 or more minute's duration).
CHARACTERISTICS
Full dilatation of the cervix, accompanied by:
Contractions (50-90 seconds duration) which may be 1 to 2 minutes apart.
Becoming increasingly expulsive in nature.
Increased show.
Expulsive grunt when exhaling.
Rectal bulging with flattening of perineum.
Increased amnesia between contractions.
Gradual appearance of presenting part at vaginal opening. (The doctor may do an
episiotomy to facilitate delivery of the baby.)
HOW THE MOTHER MAY FEEL
Increasingly involved in birth process. She may also feel:
Relief because second stage has begun.
Desire to bear down or push.
Tremendous satisfaction with each push or, conversely, acute pain with each push.
Desire to move bowels.
Complete exhaustion after each expulsive contraction.
Unable to follow directions readily.
Desire to participate fully in total birth process or, conversely to be "put to sleep".
Desire to look into overhead mirror to watch baby emerge.
A splitting sensation due to extreme vaginal stretching as baby is born.
WHAT THE NURSE MAY DO TO SUPPORT THE MOTHER
A. Verify that cervix is completely dilated by examining mother rectally or vaginally if
time permits, or asking doctor to do so.
B. If dilatation is complete, let mother know:
1. that time to work with contractions is at hand.
2. that she will be advised what to do, when.
69
Appendix J/Stages of Labor
RNSG 2462
Stage Two (continued)
C. If mother is in her own bed
1. When contraction starts, encourage her to:
a. bend knees and spread them apart.
b. open mouth and take deep breath.
c. close mouth; hold breath (no more than 5 sec.) and simultaneously:
(1) grasp knees and pull them up toward shoulders. (Support the mother's
feet, if necessary.)
(2) raise head and incline it forward.
(3) pull in lower abdomen and bear down.
(4) relax pelvis floor muscles.
2. When contraction ends, encourage mother to:
a. exhale with deep sigh; lower knees; extend legs.
b. relax.
D. If mother is en route to delivery room and has urge to push with contraction,
encourage her to blow.
E.
If mother is on delivery table:
1. adjust overhead mirror so that mother may watch birth.
2. when contraction starts, encourage mother to
a. open mouth and take deep breath. (A whiff of anesthetic may help her.)
b. close mouth; hold breath (no more than 5 seconds) and simultaneously:
(1) grasp handgrip and pull them hard.
(2) raise head and incline it forward.
(3) pull in lower abdomen and bear down.
(4) relax pelvic floor muscles.
F.
If the doctor asks mother not to push, encourage her to blow.
G. When contraction ends:
1. Encourage mother to:
a. exhale with deep sigh.
b. relax.
2. Check fetal heart. Let doctor know rate and quality. If appropriate.
a. apply cool damp cloth to mother's forehead.
b. moisten mother's lips with cool wet cloth or let her suck it.
c. commend mother for her effort.
70
Appendix J/Stages of Labor
RNSG 2462
Stage Three - The Placental Stage
THE PLACENTAL STAGE
This period begins with the birth of the baby and ends with the expulsion of the placenta and
membranes (1-20 or more minutes).
CHARACTERISTICS
Contractions temporarily cease upon birth of baby. When they resume, they usually are painless
and may be accompanied by:
Upward rise of uterus in abdomen.
Uterus assuming globular shape.
Visible lengthening of umbilical cord as placenta moves into vagina.
Trickle or gush of blood.
HOW MOTHER MAY FEEL
Exhausted but elated and proud of achievement, she may feel:
Eager to hear and see baby.
A sense of relief.
Delight that abdomen is flat.
Ravenously hungry.
Thirsty.
WHAT THE NURSE MAY DO TO SUPPORT THE MOTHER
A. Respond acceptingly to mother's emotion
B. When appropriate:
1. enable mother to see baby before it is placed in crib. Let her touch it, if possible.
2. adjust overhead mirror so that mother may watch expulsion of placenta.
3. if doctor did episiotomy, encourage or divert mother while he sutures perineum.
4. commend mother for effort or patience.
5. encourage relaxing and using breathing techniques while physician does manual
exam.
71
72
RNSG 2462
OBSTETRIC VOCABULARY
1. Acrocyanosis
Blue color of hands and feet in most infants at birth that may persist for
7 to 10 days.
2. Apgar score
Numeric expression of the condition of a newborn obtained by rapid
assessment at 1 to 5 minutes of age.
3. Areola
Pigmented ring of tissue surrounding the nipple.
4. Bilirubin
Yellow or orange pigment that is a breakdown product of hemoglobin.
1. Caput succedaneum
Swelling of the tissue over the presenting part of the fetal head caused
by pressure during labor.
6. Cephalhematoma
Extravasation of blood from ruptured vessels between a skull bone and
its external covering, the periosteum. Swelling is limited by the
margins of the cranial bone affected.
7. Colostrum
Yellow secretion from the breast containing mainly serum and white
blood corpuscles preceding the onset of true lactation 2 to 3 days after
delivery.
8. Episiotomy
Surgical incision of the perineum performed during second stage of
labor to facilitate delivery and to avoid laceration of the perineum.
9.
Broad area, or soft spot, consisting of a strong band of connective
tissue contiguous with cranial bones and located at the junctions of the
bones.
Fontanel
1. Hyper
bilirubinemia
Elevation of unconjugated serum bilirubin concentrations.
11. Lanugo
Downy, fine fair characteristic of the fetus between 20 weeks gestation
and birth that is most noticeable over the shoulder, forehead, and
cheeks but is found on nearly all parts of the body.
12. Lochia
Vaginal discharge during the puerperium consisting of blood, tissue,
and mucous.
13. Moro’s reflex
Normal, generalized reflex in a young infant elicited by a sudden loud
noise or by striking the table next to the child, resulting in flexion of the
legs, an embracing posture of the arms, and usually a brief cry—also
called startle reflex.
73
RNSG 2462
OBSTETRIC VOCABULARY
14. Multipara
Woman who has carried two or more pregnancies to viability, whether
they ended in live infants or stillbirths.
15. Para
Term used to refer to past pregnancies that reached viability regardless
of whether the infant was dead or alive at birth.
16. Perineum
Area between the vagina and rectum in the female.
17. Puerperium
Period of time following the third stage of labor and lasting until
involution of the uterus.
18. Rh Factor
Inherited antigen present on erythrocytes.
74
MOM-BABY
Clinical Preparation Requirements
You will not pick up a patient the day before-you will be assigned 1 couplet (mom and baby) when you arrive at
the postpartum floor. You will provide total patient care to both the mother and her infant including charting
and giving ordered medications.
Did you do each of these BEFORE going to Postpartum?
_____ Review the Mom-Baby site tool objectives and site tool hints found on WebCT.
_____ Complete the drug cards for postpartum and newborn (these must be HANDWRITTEN.)
_____ Review the “Breast Care and Breastfeeding Study Guide” and the “Postpartum Study Guide” found in
your syllabus.
_____ Review the postpartum chapters in your OB textbook.
_____ Review the “Obstetric Database”, if applicable, so that you are aware of the information you will need to
gather to complete the database.
_____ Review UMC orientation packet for “Perinatal areas”.
_____ Review Newborn study guide and computer charting for mom and newborn.
_____ Review nursing video skills DVD. (optional)
Bring these things with you to Postpartum:
_____
_____
_____
_____
_____
Print a copy of the Mom-Baby site tool on WebCT to bring to clinicals to gather needed information.
The “Postpartum Study Guide”
Completed Postpartum and new born drug cards.
Obstetric Database to gather patient information (if applicable).
Completed Newborn Study Guide.
_____ Nursing Process with 1 Diagnosis turned in on Tuesday following the clinical rotation. (see nursing
process guidelines for more information on p. 181)
_____ “Mon-Baby Charting Sheet” (bring 2-3 copies)
_____ “Newborn Assessment” (bring 2-3 copies)
75
SOUTH PLAINS COLLEGE
NURSING PROCESS
Client’s Initials____________
Student______________________
Diagnosis ________________
Date________________________
Age _______ Rm__________
Instructor____________________
ANALYSIS
Problem/Nursing
Diagnosis
PLAN
Goal Statements
with
Outcome Criteria
IMPLEMENTATION
Nursing Orders
Scientific
Rationale
EVALUATION
Evaluative Outcome
Criteria
76
SOUTH PLAINS COLLEGE
NURSING PROCESS
Client’s Initials____________
Student______________________
Diagnosis ________________
Date________________________
Age _______ Rm__________
Instructor____________________
ANALYSIS
Problem/Nursing
Diagnosis
PLAN
Goal Statements
with
Outcome Criteria
IMPLEMENTATION
Nursing Orders
Scientific
Rationale
EVALUATION
Evaluative Outcome
Criteria
SOUTH PLAINS COLLEGE
NURSING PROCESS
Client’s Initials____________
Student______________________
Diagnosis ________________
Date________________________
Age _______ Rm__________
Instructor____________________
77
ANALYSIS
Problem/Nursing
Diagnosis
PLAN
Goal Statements
with
Outcome Criteria
IMPLEMENTATION
Nursing Orders
Scientific
Rationale
EVALUATION
Evaluative Outcome
Criteria
SOUTH PLAINS COLLEGE
NURSING PROCESS
Client’s Initials____________
Student______________________
Diagnosis ________________
Date________________________
Age _______ Rm__________
Instructor____________________
ANALYSIS
Problem/Nursing
Diagnosis
PLAN
Goal Statements
with
Outcome Criteria
IMPLEMENTATION
Nursing Orders
Scientific
Rationale
EVALUATION
Evaluative Outcome
Criteria
78
SOUTH PLAINS COLLEGE
NURSING PROCESS
Client’s Initials____________
Student______________________
Diagnosis ________________
Date________________________
Age _______ Rm__________
Instructor____________________
ANALYSIS
Problem/Nursing
Diagnosis
PLAN
Goal Statements
with
Outcome Criteria
IMPLEMENTATION
Nursing Orders
Scientific
Rationale
EVALUATION
Evaluative Outcome
Criteria
79
SOUTH PLAINS COLLEGE
NURSING PROCESS
Client’s Initials____________
Student______________________
Diagnosis ________________
Date________________________
Age _______ Rm__________
Instructor____________________
ANALYSIS
Problem/Nursing
Diagnosis
PLAN
Goal Statements
with
Outcome Criteria
IMPLEMENTATION
Nursing Orders
Scientific
Rationale
EVALUATION
Evaluative Outcome
Criteria
80
RNSG 2462 - Newborn Study Guide
Student Name: ____________________________________________
The study guide answers must be handwritten. Typed copies NOT accepted.
1. For a normal term infant:
weight _________________________grams______________________lbs./oz.
length ___________________________cm.______________________inches
FOC _____________cm _____________in
Chest _____________cm_______________in.
Vital Signs:
Temperature ____________________________________
Heart Rate __________________________ Respirations___________________
BP________________________________
Why is the BP taken in all four extremeties on admission to the nursery?
Briefly describe or define the following parameters of a newborn physical assessment.
2. Color:
a. Pink
b. Pale
c. Plethoric
d. Flushed
e. Gray
f. Acrocyanosis
g. Central cyanosis
h. Jaundice
i. Mottled
j. Meconium stained
81
3. Cry
a. Strong, lusty
b. Shrill, high pitched
c. Weak
d. Hoarse
e. No cry
4. Activity
a. Active
b. Hypoactive
c. Hyperactive
d. Flaccid
e. Jittery
5. Skin
a. Peeling
b. Perspiring
c. Turgor
d. Edema
e. Petechiae
f. Cyanosis
g. Rash
h. Birthmarks
i. Jaundice
j. vernix
k. Desquamation
82
l. Acrocyanosis
m. Ashen
6. Head
a. Caput
b. Molding
c. Cephalohematoma
d. Symmetry
7. Face
a. Bruising
b. Lacerations
c. Facial weakness
d. Milia
8. Fontanelles
a. Size: Posterior___________________Anterior__________________________
b. Shape: Posterior __________________ Anterior _______________________
c. Soft
d. Flat
e. Depressed
f. Bulging
9. Eyes
a. Subconjunctivial hemorrhage
b. Icteric
c. Edema
83
d. Blink reflex
10. Ears
a. Low set
b. Abnormal shape
c. Skin tags
d. Cartilage
11. Nose
a. Obstruction (how would you check for patency?)
12. Mouth
a. Protruding tongue
b. Precocious teeth
c. Cleft lip
d. Cleft palate
e. Epstein Pearls
f. Droop
13. Neck
a. Mobility
b. Webbing
c. Masses
d. Fractured clavicle
14. Heart Sounds
a. S1 and S2
84
b. PMI location
15. Pulses
a. Brachial
b. Femoral
16. Respirations
a. Retractions (note differences between subcostal, intercostal, substernal &
sternal)
b. Tachypnea
c. Periodic breathing
d. Grunting
e. Nasal flaring
f. Symmetry
17. Breath Sounds
a. Ronchi
b. Rales
c. Dimished
18. Abdomen
a. Round
b. Scaphoid
c. Distended
d. Loops
e. Bowel sounds
19. Umbilical cord
85
a. Normal
b. Pulsating
c. Meconium stained
d. Drainage
e. Cord care
20. Back
a. Spine curvature
b. Myelomeningocele
c. Mongolian spots
d. Sacral dimple
e. Lanugo
21. Extremeties
a. Paralysis
b. Hip click
c. Hands & Feet:
Extra digits
Webbed digits
Skin tags
Sole creases
22. Genitalia & breasts
a. Scrotom
Testes
86
Ruggae
b. Hypospadias
c. Hymenal tag
d. Pseudomenstruation
e. Witches milk
f. Urine output
g. Circumcision
23. Rectum
a. Patency
b. Imperforate anus
c. Fistula
d. Stool
24. Reflexes
a. Moro
b. Babinski
c. Grasp
d. Plantar
e. Stepping or dancing
f. Arm & leg recoil
g. Rooting
h. Swallowing
i. Sucking
25. Describe the Ballard Score parameters
87
RNSG 2462-CLINICAL DRUG CARDS
POSTPARTUM
THESE MUST BE HANDWRITTEN-NO TYPED CARDS WILL BE ACCEPTED. Complete the drug cards
for these medications using the Postpartum drug cards forms in the syllabus. The faculty will critique at the
clinical setting. Be prepared to discuss the appropriate drugs for your patient.
Depo Provera
Dermoplast
Doxidan/Colace
Lortab/Vicodan
Motrin
Niferex (iron supplement)
Prenatal Vitamin (PNV)
RhoGAM
Rubella Vaccine
Simethicone
Tdap vaccine
Toradol (I.V.)
Tucks
88
POSTPARTUM DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
POSTPARTUM USE________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
POSTPARTUM DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
POSTPARTUM USE________________________________________________________________________________
__________________________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
89
POSTPARTUM DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
POSTPARTUM USE______________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
POSTPARTUM DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
POSTPARTUM USE_______________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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POSTPARTUM DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
POSTPARTUM USES ______________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
POSTPARTUM DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
POSTPARTUM USES_______________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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POSTPARTUM DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
POSTPARTUM USES_______________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
POSTPARTUM DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
POSTPARTUM USES______________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
92
POSTPARTUM DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
POSTPARTUM USES_______________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
POSTPARTUM DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
POSTPARTUM USES _______________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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POSTPARTUM DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
POSTPARTUM USES _______________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
POSTPARTUM DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
POSTPARTUM USES_______________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
94
POSTPARTUM DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
POSTPARTUM USES _______________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
POSTPARTUM DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
POSTPARTUM USES_______________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
95
POSTPARTUM DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
POSTPARTUM USES _______________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
POSTPARTUM DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
POSTPARTUM USES_______________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
96
Breast Study Guide
RNSG 2462
SOUTH PLAINS COLLEGE
ASSOCIATE DEGREE NURSING PROGRAM
BREAST CARE AND BREAST FEEDING STUDY GUIDE
This study guide will focus on breast care and breast feeding the newborn. At the completion of this module,
you should be able to instruct your patient on breast care and breast-feeding. Please put the page number and
source by each answer.
Situation
Erica Sams has just delivered a 7-pound baby boy and has made the decision to breast-feed.
1. Please label the following structures of the breast.
2. Describe how breast milk is delivered to the infant.
3. Discuss the following types of nipples and explain how each type interferes with breastfeeding.
a. fissured
b. inverted
97
Breast Study Guide
RNSG 2462
4. List and describe the hormones related with breast-feeding.
5. Describe Colostrum
6. What are the advantages of breast feeding for:
A. The mother?
B. The infant?
7. Discuss nursing care for these common problems associated with breast-feeding.
Positioning infant for breast-feeding.
A. Sore nipples
B. Engorgement
C. Uninterested infant
D. Decrease in milk supply
E. Burping
F. Plugged ducts
8. How will you instruct the patient to properly clean her breast?
9. Discuss length of nursing times and tell why the length of time should be gradually
increased.
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Breast Study Guide
RNSG 2462
10. List the criteria that indicate to the mother that the infant is satisfied.
Criteria for the dissatisfied infant
11. Discuss how drugs taken by the mother affect the infant and give at least three 3
drug classifications that will affect the infant.
12. What are some problems associated with nursing twins?
13. What problems are encountered in nursing the premature or low birth weight infant?
14. What is the let down reflex and how important is this reflex in successful breast
feeding?
15. What would you tell a mother who is concerned about a "demand feeding" schedule?
16. What is the normal start cycle of the breast-fed infant?
17. How early and regular lactation is established?
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Breast Study Guide
RNSG 2462
18. How many calories does breast milk contain?
19. What changes will occur in the diet of the breast-feeding mother?
20. What can be done to help the father of the breast-fed infant feel helpful?
21. Can a woman work and breast feed?
22. Discuss ways to help the working mom be successful in continuing breast-feeding.
100
Postpartum
RNSG 2462
POSTPARTUM STUDY GUIDE
Overview:
The puerperium (postpartum) is the period of time during which the body adjusts both physically and
psychologically, to the process of childbearing. It begins immediately after childbirth and proceeds for
approximately six weeks, or until the body has completed its adjustment and has returned to a near pre-pregnant
state. Some have referred to the puerperium as “the fourth trimester: and, whereas the time span does not
necessarily cover three months, this terminology demonstrates the idea of continuity. The term involution is
used to describe the rapid reduction in size of the uterus and its return to a condition similar to its pre-pregnant
state.
Nursing Objectives in the Normal Postpartum:

To monitor maternal physiologic and psychological adaptation in the early postpartum period.

To promote the restoration of maternal bodily functions.

To promote maternal rest and comfort.

To promote patent-infant acquaintance.

To facilitate parental caretaking.

To teach effective self-care and infant care.
Possible Nursing Diagnoses Related to Normal Postpartum:

Anxiety related to breast-feeding.

Alterations in bowel elimination (constipation) related to decreased bowel motility and perineal/rectal pain.

Alteration in comfort (pain) related to uterine contractions and lacerations of the perineum or rectum.

Fluid volume deficit related to abnormal fluid loss and dehydration.

Alteration in patterns of urinary elimination related to bladder trauma and post delivery diuresis.

Alteration in family processes related to new family member.
101
Appendix L/Postpartum
RNSG 2462
POSTPARTUM ASSESSMENT
VITAL SIGNS:

Monitor BP, pulse, skin color, uterine tone, and vaginal bleeding q 15 minutes X 1 hr., the q 30 min. X 2,
then hourly for 6 hours. (This is a guide—VS will have to be done more frequently if complications exist.)
Monitor temperature q 4 hours.

When taking the patient’s blood pressure, note that:
The patient’s blood pressure should not change significantly during the postpartum period.
Hypotension indicates possible hypovolemia.
The first signs of PIH may become apparent during the postpartum period.

When taking the patient’s temperature, keep in mind that:
Oral temperature of the postpartum woman within 24 hours of delivery may be as high as 100.40 F
resulting from muscular exertion or dehydration; after 24 hours she should be afebrile.
Elevations after the first 24 hours suggest sepsis, endometritis, urinary tract infection, mastitis, or
another infection. An elevated temperature during this period should be reported to the doctor or nurse
midwife for further evaluation.

When measuring the patient’s pulse rate, remember:
Bradycardia is common for 6-8 days after delivery (50-70 beats/minute is considered
normal).
Pulse rates greater than normal may indicate infection or hypovolemia.
Respiratory rate should be within normal range.
FUNDUS:

Asses fundal status for height and firmness. The fundus should feel firm (or hard) and be midline at the
level of the umbilicus after delivery. It should also descend approximately 1 cm/day thereafter. (See
following diagram.)
102
Appendix L/Postpartum

RNSG 2462
Recording fundal findings:
Fundal height is recorded in fingerbreadths. Example:
U/U = means the fundus is level with the umbilicus.
1/U = means the top of the fundus is 1 fingerbreadth above the umbilicus.
U/1 = means the top of the fundus is 1 fingerbreadth below the umbilicus.
See diagram:
TABLE 14-1 Lochial Characteristics
Rubra
Color
Bright red; bloody
Clots
Small clot
Odor
Slightly “fleshy”
Length
1-3 days

Serosa
Pink-brown
No clots
No odor
5-7 days
Alba
Creamy white
No clots
No odor or stale body odor
1-3 weeks
Keep in mind while assessing the fundus:
Patients who breast-feed may experience a more rapid involution of the uterus as a result of the release
of oxytocin from the posterior pituitary during nursing.
An elevated fundus that is displaced to the right suggests a full bladder.
A flaccid or “boggy” fundus indicates uterine atony and should be massaged until firm.
Gently palpate the uterus of a Cesarean birth mother to assess level of fundus, surgical
dressing for drainage or bleeding, and check the degree of pain being experienced.
Most postpartum patients receive oxytocin in their IV fluids to prevent uterine atony.
Review Oxytocin (Pitocin)
Prostin IM
Methergine
103
Postpartum

RNSG 2462
A complete Nursing Note documenting normal findings might be:
Fundus firm (F.F.), U/1, lochia rubra, small amount.
LOCHIA:

Lochia are the discharge from the uterus of blood, mucus, and tissue during the puerperal period and are
classified according to its appearance and contents. See chart.
Characteristics of Lochia

When assessing lochia, note:
The amount (excessive, large, moderate, or scant). Bleeding is assessed in a peri pad. Rule of thumb: 1 ml blood
= 1 gram. (For a more accurate measurement of blood loss, the peri pads or linen savers can be weighed.)
Note character (rubra, serosa, or alba). See above chart.
Excessive lochia rubra that occurs with a relaxed (or boggy) uterus results from uterine atony; with a firm uterus,
from lacerations. Foul smelling lochia is usually associated with infection.
Usual blood loss following vaginal delivery could be as high as 500 ml. A blood loss of 700-1000 ml following a
Cesarean section is not uncommon.
BLADDER:

Labor and delivery may affect the tone of the bladder or cause edema of the tissues surrounding the urethra, thereby
making voiding difficult. Patients who have had epidural anesthesia frequently have difficulty voiding. A full
bladder may cause the fundus to deviate to the right, climb above the umbilicus, and predispose the patient to uterine
atony and subsequent hemorrhage. Catheterization may be necessary if nursing measures are unsuccessful. The
patient should be voiding sufficient quantities (at least 250-300 ml) every 4-6 hours.
104

Appendix L/Postpartum
RNSG 2462
URINE OUTPUT:
Marked diuresis begins within 12 hours after delivery. Check the bladder for distention every 4-6 hours; a full
bladder may prevent uterine contraction and may predispose the patient to hemorrhage. Anesthesia or trauma
during labor and delivery may predispose the patient to urinary retention.
ELIMINATION:
Stool softeners, laxatives, suppositories, or enemas may be necessary for the postpartum patient. The patient
may also benefit from a high-fiber diet to help stimulate peristalsis. Note the following:

Decreased muscle tone during pregnancy may cause constipation.

Hemorrhoids, common during pregnancy, may have become aggravated by pushing while in labor.
Preventing constipation is essential for patients with hemorrhoids.

Patients who have had extensive perineal repair should be given stool softeners daily to prevent trauma to
the suture lines during defecation.
PAIN:
Afterpains, caused by uterine contractions, are most common in multiparas and in breast-feeding patients. You
may need to administer per MD orders analgesics for after pains or perineal pains.
NUTRITION:
Patients who breast-feed require 500 extra calories a day increased fluid intake and should continue taking
prenatal vitamins. If the patient is anemic, she may also be given an iron supplement. She needs to also be
made aware of the need for vitamin C in her diet to assist in the iron absorption.
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Appendix L/Postpartum
RNSG 2462
EMOTIONAL ADJUSTMENT TO PARENTING:
Postpartum patients usually adjust to the emotional aspects of parenting in phases.
*
During the first 2 days of the postpartum period (taking-in phase), the patient is frequently preoccupied
with her own needs.

Throughout the next 10 days (taking-hold phase), the patient strives for independence and is concerned
about the return of normal bodily functions. Her first mothering tasks are important, and nursing support
and encouragement are essential.

Eventually, the patient realizes and accepts her physical separation from the baby and relinquishes her
former role as a childless person (letting-go phase).

Evaluate the patient for signs of abnormal behavior, including persistent insomnia, lack of appetite, distant
and aloof attitude toward her newborn and excessive somatic complaints having no physical basis.
LABORATORY DATA:
Note the following information regarding test results for the postpartum patient:
*
In many cases the patient's hematocrit level is falsely elevated because of rapid loss of plasma.

The white blood count usually increases during the postpartum period.

Coagulation factors usually increase during pregnancy and the early postpartum period; this predisposes the
patient to thrombophlebitis.
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Appendix L/Postpartum
RNSG 2462
ONGOING POSTPARTUM ASSESSMENT
During the ongoing assessment, continue monitoring the information given in the previous pages and observe
the following:
BREAST:

For breast-feeding patients, note the following:

Expect the patient to secrete colostrum for the first few days after delivery. Then, on the 2nd or 3rd day
postpartum, the breast should tense as a result of the beginning of milk production. Engorgement may occur
on the 3rd or 4th day.

Examine the breast q 8 hours for signs of mastitis (heat, redness, or masses).

Examine the nipples for shape, cracks, fissures, or soreness.

Advise the patient to wear a well-fitting support bra 24 hours a day.
For bottle feeding patients, note:
*
Examine the breasts for signs of engorgement, mastitis, or masses.

Advise the patient to wear a good support bra 24 hours a day.

Advise patient, if she becomes engorged, don't pump; continue to wear support bra and Tylenol ES q 4
hours prn may be ordered.
EXTREMITIES:
Examine the patient's legs for edema, redness, heat, pedal pulses, or a positive Homan's sign (see diagram).
Because blood-clotting factors are increased during pregnancy, the patient may be predisposed to
thromboembolism. Early ambulation promotes circulation to the extremities and helps minimize the incidence
of thrombophlebitis.
It is also very important to instruct the patient that has had epidural anesthesia to get help from a nurse at least
the first time she gets up to void after delivery. First of all, she may faint, and secondly, although she is able to
move her legs, she may not as yet have the knee locking motion needed to get to the restroom.
107
Postpartum
RNSG 2462
PERINEUM:
Assess the perineum and episiotomy for redness, edema, ecchymosis, discharge, approximation of wound edges, and
pain.
**Must! In order to completely assess the episiotomy, you must have the patient lie on one side with the upper leg
drawn up, raise the upper buttock, and assess the episiotomy and perineal area all the way to the rectal area.
Examine the anal area for hemorrhoids.
Usually ice packs are applied to the perineum area for about 8 hours, but be sure to check the orders.
On the first postpartum day, warm sitz baths and heat lamps may be used for comfort, minimize infection, and
promote healing.
The patient will need teaching regarding proper cleaning after voiding or defecation, and changing peri pads
frequently.
*
Rh negative patients require an antibody screen (indirect Coomb's test) postpartum. If the test is negative and the
newborn is Rh positive, RH. (D) immune globulin must be given within 72 hours of delivery.

If the patient is not immune to rubella virus, vaccination should occur before discharge.
108
RNSG 2462
NEWBORN /TRANSITION NURSE
Clinical Preparation Requirements
You will not pick up a patient assignment the day before-you will be working with the nurses in labor &
delivery who will be transitioning newborn infants.
Did you do each of these BEFORE going to the newborn nursery/resource nurse?
_____
_____
_____
_____
_____
_____
_____
Review the newborn transition site tool objectives and site tool hints on WebCT.
Complete the drug cards for the newborn (these must be HANDWRITTEN)
Read the “Examination of the Newborn” guide in your syllabus.
Review the “Newborn Assessment Study Guide” found in your syllabus.
Read the UMC “Perinatal Area” orientation packet regarding the newborn nursery.
Read chapters 19 through 23 in the OB textbook (Suggestion: Read chapter 20 carefully)
Review the UMC orientation packet on “Preinatal Area”
Bring these things with you to the Newborn Nursery rotations:
_____ Print a copy of the newborn transition site tool on WebCT to help in gathering needed information.
_____ Completed newborn nursery drug cards.
_____ The completed “Newborn Assessment Study Guide” from your syllabus.
109
RNSG 2462-CLINICAL DRUG CARDS
NEWBORN
THESE MUST BE HANDWRITTEN-NO TYPED CARDS WILL BE ACCEPTED. Complete the drug cards
for these medications using the Newborn drug card forms in the syllabus. The faculty will critique them at the
clinical setting. Be prepared to discuss the appropriate drugs for you patient.
Aqua Mephyton (Vitamin K)
Erythromycin Ophthalmic ointment
Hepatitis B Vaccine
Narcan
110
NEWBORN DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
NEWBORN USES__________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
NEWBORN DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
NEWBORN USES__________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
111
NEWBORN DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
NEWBORN USES__________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
NEWBORN DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
NEWBORN USES__________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
112
NEWBORN DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
NEWBORN USES__________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
NEWBORN DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
NEWBORN USES__________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
113
NEWBORN DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
NEWBORN USES__________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
NEWBORN DRUG CARDS
STUDENT NAME___________________________________
BRAND NAME______________________________GENERIC NAME_______________________________________
CLASSIFICATION_________________________________________________________________________________
RECOMMENDED DOSAGE/FREQUENCY_____________________________________________________________
MECHANISM OF ACTION__________________________________________________________________________
__________________________________________________________________________________________________
USES_____________________________________________________________________________________________
NEWBORN USES__________________________________________________________________________________
ADVERSE REACTIONS_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTRAINDICATIONS_____________________________________________________________________________
__________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS/INCOMPATIBILITY_____________________________________________________
__________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
114
Exam of Newborn
RNSG 2462
SOUTH PLAINS COLLEGE
ASSOCIATE DEGREE NURSING PROGRAM
EXAMINATION OF THE NEWBORN
GENERAL INSPECTION
Undress the baby, using a good light and a flat surface. Note general body conformation and
relationship of the parts to the whole.
A. Average weight: 7 to 7 ½ lb., range 5 ½ to 10 lb. Under 5 ½ lb. considered “premature by weight”
Length range: 19 to 21 inches
Head circumference: average 13 ½ inches for term baby F.O.C. greater than nipple-line
circumference in many infants until 6 to 8 months (approximately 1 inc.).
B. Color: Note whether pink, ashen, cyanotic, yellow. If the baby is in good condition otherwise,
cyanosis of palms and soles is not significant (acrocyanosis).
C. Body tone: Infant lies with elbows, knees, and thighs flexed: hands clenched, thorax rigid. Lying
supine, he exhibits spontaneous movements of arms and legs.
D. Respirations: Newborn nose breaths normally. Check respirations at rest: Average 40/min.
Abdominal, irregular.
II.
SKIN
The newborn is sensitive to touch and pressure.
Communicate loving care when you touch him.
If baby is cold there may be generalized mottling.
Vernix, if any, should be white.
Lanugo may be present on dorsal surfaces, will disappear in a few weeks.
Flat, pink hemangiomas will disappear in a few months.
Mongolian spots and phalangeal smudges present in very dark babies.
III.
REFLEXES NORMALLY PRESENT IN TERM INFANTS
Most of the reflexes can be elicited during the general inspection, and unless there is doubt, it is not
necessary to make a sequence of tests.
A. Moro Reflex: Response to sudden movement, jarring, or imbalance. Extremities are flung to the
midline, wrists and hands curl. If absent, indicates diffuse cerebral damage.
B. Cry: Low-pitched, “one note” cry.
C. Rooting Reflex: Touch infant’s cheek/lips on one side, he will open his mouth and seek food. (If he
is not hungry, he may not oblige).
115
Exam of Newborn
RNSG 2462
D.
E.
F.
G.
Sucking Reflex follows rooting.
Swallowing Reflex: A previable reflex – the foregoing are not.
Sneezing Reflex: Well-developed, may be a response to lint particles. (He doesn’t have a cold.)
Grasp Reflex: Involuntary grasp elicited by placing your finger in baby’s hand or at base of toes.
Disappears by 4 to 5 months and voluntary grasp appears.
H. Plantar Reflex: (Not a true Babinski) Toes fan out. May persist to end of second year.
I. Dancing Reflex: With palm of your hand along infant’s nipple line, hold him forward. His steps
should be evenly spaced.
J. Tonic Neck Reflex: Fencing position when lying supine.
IV.
HEAD
When lying prone, the infant can raise and turn his head momentarily in turtle-like movements.
Development of neck and cheek structures is not sufficient to support the head.
May be asymmetrical due to intrauterine position or molding (with overriding of the bones at suture
lines). Anterior fontanel averages 2 X 2 cm at birth, posterior fontanel is closed to 1-cm diameter.
Fontanels sometimes increase in size due to reduction of overriding skull bones.
Caput succedaneum: Edema of scalp disappears 1 to 3 days.
Cephalhematoma: Subperiosteal hemorrhage disappears 2 to 6 months.
Ears: Upper part implanted in the same horizontal plane as the eye. Low implantation associated with
chromosomal aberrations. Regarding this, also look for fat pads in nape and parotid areas.
V.
FACE
Look for facial characteristics and mobility, closed mouth, (unless you made him cry), blinking at light,
etc.
Symmetry of facial movements: observe during crying. Tear ducts sometimes closed. Yellow matter
collects during sleep. Conjunctivitis not a factor, unless tissues inflamed.
116
Exam of Newborn
VI.
RNSG 2462
MOUTH
The mouth is best examined when the infant is crying, if possible. A flashlight and tongue depressor
may be necessary. Be sure to see the whole expense of hard and soft palate. Even a small V-shaped
nick in the soft palate will produce a speech defect.
Inclusion cysts on hard palate in midline. Disappear in a few months.
“Tongue-tie” does not require clipping, if baby can extrude tongue.
Growth of tongue is forward from frenulum during the first year.
Observe for healthy mucous surface.
VII.
NECK
Support the baby with your hand over the area of the trapezius and allow the head to fall back enough to
expose the neck.
Palpate for masses, (hygromas are almost always unilateral); feel for intact clavicle.
VIII.
CHEST
Chest movements symmetrical.
Circumference at nipple line equal to, or smaller than head circumference. Engorgement of breasts with
production of secretion may be present in term infants. Duration about 1 to 2 weeks.
Heart rate: 110 to 150. Report heart sounds heard on right, (displaced mediastinum).
IX.
ABDOMEN
If examined early, look for 2 umbilical arteries and 1 vein. Presence of only one artery is associated
with congenital malformations—renal and gastric.
Abdomen more or less rounded, full in the flanks, but not tight.
Bowel sounds are present at 1 hour of age.
Liver extends 2 cm below right costal margin.
Xiphoid cartilage prominent.
Peristalsis may be observed.
If abdominal muscles absent, there is a “seersucker” appearance.
X.
GENITALIA
Genitals appear large for size of infant due to maternal hormones. Examine male external meatus for
location. Testes descend at 8 months gestation. Newborn girls have creamy white mucous coating labia
minora and sometimes pseudo menstruation. Palpate labia majora for translocated tissue, (ovary), etc.
117
Exam of Newborn
XI.
RNSG 2462
EXTREMITIES
Inspect for dislocated hip: Abduct hips to from position with infant in back-lying position, hips should
spread. With infant prone, look for extra, major gluteal folds.
Check for range of movement of feet: clubfoot does not reduce.
XII.
SPINE
Holding baby as for dancing reflex, observe for longitudinal and lateral flexibility of spine. Palpate for
normal outline, dermal tracts, etc.
118
PEDIATRICS
Clinical Preparation Requirements
You will pick up a patient assignment the day of your scheduled rotation and you will provide total patient care to the
patients you are assigned. The student may not remove the e-MAR copy from the hospital.
Did you do each of these BEFORE going to the Pediatrics rotation?
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Find your patient assignment in the SPC ADN book located in the Pediatrics medication room.
Complete your drug cards from the MAR copy in the assignment notebook.
Read the patient’s chart (especially the doctor’s progress notes)
Check the doctor’s orders with the MAR (Medication Administration Record) and initial the MAR.
Find your patient’s medication in the med room (Hint: look in the patient drawers and in the refrigerator located
in the med. room)
Complete the Pediatric Prep Sheet information on each assigned patient (include 3-4 possible diagnoses on the
Process sheet).
READ the policy and procedures appropriate for your patient (i.e. central line medication administration; G-tube
feeds or medications; dressing changes; I.V. flush information, etc.)
Review the pediatrics site tool objectives found on WebCT.
Read the UMC “Pediatrics” orientation packet material (Hint: there is a charting example in this that you may
find helpful).
Review the “Developmental Approaches to Physical Assessment” and “Preparation of Pediatric Medications”
from your syllabus.
Review the “Pediatric Database” and be ready to collect information (if applicable).
Read the appropriate text chapters related to Pediatric assessment.
Review video skills DVD. (Optional)
Bring these things with you to the Pediatrics rotations:
_____
_____
_____
_____
_____
_____
Completed drug cards. (Including calculations appropriate for you patient)
Pediatrics site tool to gather needed information.
Pediatric Database (if applicable) so you may collect information.
Pediatric drug book
UMC Pediatrics orientation packet
Completed Pedi Prep sheets on each assigned patient and process sheet with 3-4 possible diagnosis for each
assigned patient.
_____ The first and last week of Pedi rotations, complete the process sheet for one chosen diagnosis on one assigned
patient to turn in on Tuesday following the rotation.
CLINICAL GUIDELINES
_____ Receive nurse to nurse report; evening students get report from day student nurse then go with day student when
gives report to TPCN and meet your patient’s TPCN.
_____ Review your patient assignment in the SPC ADN book located in the Pediatrics medication room.
_____ Review current MAR for new orders and notify instructor of any new orders.
119
Pediatric Assessment
RNSG 2462
DEVELOPMENTAL APPROACHES TO PHYSICAL ASSESSMENT
The traditional steps in physical assessment—inspection, palpation, percussion, and auscultation—are the
same for children as for adults. They should be used not only to gather information about the child but also as a
time to teach the child or his parents about health care. Physical assessment requires that use of a systematic
approach along with the patience, tact, and sensitivity to the needs of the child and his parents. To avoid a loss
of interest, chilliness and irritability of the child, the assessment should be completed in 5 to 10 minutes.
Positive statements should be made to the child and not allow a choice if there is no choice. For example,
“John, not it is time to take your clothes off,” rather than, “John, will you please take your clothes off.” You
can offer a choice of “John, do you want to take off your pants or your shirt first?”
The child should be positioned either on the examining table or in the parent’s lap depending on the age of
the child. General approaches to physical examination during childhood are listed on the following chart on the
following pages.
You should begin your assessment moving slowly and avoiding sudden, jerky movements. You must be gentle
but firm in handling the child and should proceed as quickly as possible.
120
RNSG 2462
Age-specific approaches to physical examination during childhood
Age
Position
Sequence
Preparation
Infant
Before sits alone: supine or
prone, preferably in parent's
lap; before 4 to 6 months: can
place on examining table.
If quiet, auscultate heart,
lungs, and abdomen.
Record heart and respiratory
rates.
Palpate and percuss same
areas.
Proceed in usual head-toe
direction.
Perform traumatic procedures
last (eyes, ears, mouth [while
crying], rectal temperature [if
taken]).
Elicit reflexes as body part
examined.
Elicit Moro reflex last.
Completely undress if room
temperature permits.
Leave diaper on male.
Gain cooperation with
distraction, bright objects,
rattles, talking.
Smile at infant; use soft gentle
voice.
Pacify with bottle of sugar
water or feeding. Enlist
parent's assistance for
restraining to examine ears,
mouth.
Avoid abrupt, jerky
movements.
After sits alone: use this
position whenever possible in
parent's lap. If on table, place
with parent in full view.
Toddler
Sitting or standing on/by parent
Prone or supine in parent's lap.
Inspect body area through
play: "count fingers," "tickle
toes".
Use minimal physical contact
initially.
Introduce equipment slowly.
Auscultate, percuss, palpate
whenever quiet.
Perform traumatic procedures
last (same as for infant).
Have parent remove outer
clothing.
Remove underwear as body
part examined.
Allow to inspect equipment:
demonstrating use of
equipment usually ineffective.
If uncooperative, perform
procedures quickly.
Use restraint when
appropriate; request parent's
assistance.
Talk about examination if
cooperative, use short phrases.
Praise for cooperative
behavior.
Preschool
child
Prefer standing or sitting.
Usually cooperative prone/
supine.
Prefer parent's closeness.
If cooperative, proceed in
head-toe direction.
If uncooperative, proceed as
with toddler.
Request self-undressing.
Allow to wear underpants if
shy.
Offer equipment for
inspection.
Briefly demonstrate use.
Make up "story" about
procedure: "I'm taking blood
pressure to see how strong
muscles are".
Use paper-doll technique.
Give choices when possible.
Expect cooperation: use
positive statement: "Open
your mouth".
121
RNSG 2462
Age-specific approaches to physical examination during childhood
Age
Position
Sequence
Preparation
School-age
Child
Prefer sitting.
Cooperative in most positions.
Younger age prefer parent's
presence.
Older age may prefer privacy.
Proceed in head-toe direction.
May examine genitalia last in
older child.
Respect need for privacy.
Adolescent
(Same as for school-age child)
Offer option of parent's
presence.
(Same as older school-age
child)
Request self-undressing.
Allow to wear underpants.
Give gown to ear.
Explain purpose of equipment
and significance of procedure,
such as otoscope to see
eardrum, which is necessary
for hearing. Teach about body
functioning and care.
Allow to undress in private.
Give gown.
Expose only area to be
examined.
Respect need for privacy.
Explain findings during
examination: "Your muscles
are firm and strong".
Matter-of-factly comment
about sexual development:
"Your breasts are developing
as they should be".
Emphasize normalcy of
development.
Examine genitalia as any other
body part; may leave to end.
122
Calculation of Dosages/Medications
RNSG 2462
SOUTH PLAINS COLLEGE
ASSOCIATE DEGREE NURSING PROGRAM
CALCULATION OF PEDIATRIC DOSAGES
Surface Area Rule
Surface area (m2)
Child’s dose = __________ X Adult dose
1.73 m2
(Surface area of adult)
Step 1
Step 2
Step 3
Plot the height (in either cm or in.) of the child in the height column.
Plot the weight (in either kg or lb) of the child in the weight column.
Draw a straight line connecting the height point and the weight point of
the child. The number where the line intersects the surface area column is the
child’s body surface area column is the child’s body surface area.
Fried’s Rule (Birth to 12 months)
Age (in months)
Infant’s dose = __________ X Adult dose
150
Young’s Rule (1-12 years)
Age (in years)
Child’s dose = __________ X Adult dose
Age (in yr.) + 12
Clark’s Rule (Child over 2 years)
Mass of child
Child’s dose = __________ X Adult dose
(Wt. in lb.)
150 lb. or 68 kg.
123
126
PREPARATION OF PEDIATRIC MEDICATIONS
RNSG 2462
To be prepared to give your pediatric medications during your clinical rotations please utilize the following
guidelines (IV meds are given by students on the Pedi floors at UMC with the exception of Toradol and
sedating medications).
1. Check the MAR (medication administration record).
2. Check the physician’s orders relating to these meds.
3. In the medication room, check the patient’s box and the med room refrigerator for the medication before
administration time. Consult with your instructor or TCPN if med is not found. (Please take the med
out of the refrigerator 1-2 hrs. before giving.)
4. Know the route and how the drug is supplied. (What is in the patient’s box or refrigerator?) Check the
supplied med against the MAR.
Is it in a pre-filled syringe from pharmacy?
Is it in a vial that must be reconstituted?
Is it a pharmacy mixed piggyback?
Is it a liquid; capsule; tablet; ointment; drops; etc.?
5. Calculate dosages using your child’s weight in kilograms. Check if the dose ordered is within normal
limits according to the calculated highs and lows, or recommended maximum dose found in your drug
book.
6. If the med is to be given IV – Know the recommended safe IV infusion rate for your child and the
method that will be used to give the med. The following are the different methods of administration
used at UMC.
A. Piggyback – Know the recommended dilution and infusion time. Does your pt. have continuous IV
infusions or an INT?
B. Syringe pump – Know the minimum amount of solution recommended for dilution and infusion.
Prepare and label the syringe. Know the recommended infusion time for the drug and safe rate for
your child and then calculate the syringe pump setting.
C. I.V. push - know the rate and dilution of medication.
7. If the med is to be given through a central line (Broviac or PICC) or gastric tube, read the policy and
procedure.
8. Complete a pediatric drug card including pediatric-related information for every drug your child is on
even if you will not be giving it. Include your calculations on the back of the card.
If a peak and trough is recommended for a drug you are to administer, check if this was ordered and if
so when was it done and what were the lab results before giving the drug.
9. If the med is not premixed from pharmacy, you must calculate the amount of volume to be given.
(Example: Dr.'s order: 230 mg Ampicillin IV q 8 hr. Have in drawer 250-mg vial you will need to
know how much diluent to reconstitute with and then calculate how much volume you will give to get
the 230-mg dose.)
127
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
128
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
129
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
130
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION______________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
131
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
132
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
133
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
134
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
135
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
136
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
137
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
138
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
139
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
140
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
141
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
PEDIATRIC DRUG CARD
PT. INITIALS ______ PT. WEIGHT ____ kgs. STUDENT NAME ___________________________REFERENCE/PAGE ___________________________
BRAND NAMES _________________________________________________________GENERIC NAME ________________________________________
CLASSIFICATION _______________________________________________________________________________________________________________
MECHANISM OF ACTION ________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
USES ___________________________________________________________________________________________________________________________
REASON PRESCRIBED FOR THIS PATIENT_________________________________________________________________________________________
CONTRAINDICATIONS __________________________________________________________________________________________________________
FOOD/DRUG INTERACTIONS /INCOMPATIBILITY __________________________________________________________________________________
________________________________________________________________________________________________________________________________
SIDE EFFECTS __________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NURSING MEASURES: ASSESS/MONITOR _________________________________________________________________________________________
________________________________________________________________________________________________________________________________
INTERVENTIONS/PT. TEACHING __________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
ROUTE ____DOSAGE / FREQUENCY ORDERED_____________________________________________________________________________________
RECOMMENDED DOSAGE / FREQUENCY _________________________________________________________________________________________
CALCULATED DOSAGE OR RANGE FOR YOUR PT._________________________________________________________________________________
FOR I.V. MEDS
CHECK INFUSION METHOD: PIGGYBACK _____
SYRINGE PUMP _______
IV PUSH _______ RETROGRADE _________
RECOMMENDED CONCENTRATION______________________________________ CALCULATED CONCENTRATION_______________________
RECOMMENDED INFUSION TIME ______________________ MINUTES
*IF MED NOT PREMIXED FROM PHARMACY CALCULATE THE AMOUNT OF MED NEEDED FROM A VIAL________________________
**PLEASE SHOW ALL CALCULATIONS ON THE BACK OF THE CARD**
142
Student Name:_____________________ Site: _________________ Date: _____________
S.P.C. RNSG 2462
PEDIATRIC CLINICAL PREPARATIONWORKSHEET
Patient Initial: __________
Vital Signs Norms: B.P.
**(For your patient’s age group)
Age
P.
lb.
kgs.
R.
T.
Date of Admission:
Surgical Procedures:
Admission Medical Diagnosis:
Diagnostic Procedures:
Additional diagnoses affecting this child:
Diet:
Pertinent or abnormal Laboratory Data:
Allergies:
Activity:
IV Therapy:
Plan for the day: List treatments, procedures and current medications scheduled for your shift
(including times).
Medical Diagnosis: _________________________________________________________
Pathophysiology:
Clinical Manifestations: Underline signs and symptoms shown by the patient.
143
Erikson’s Developmental Level Information:
Piaget Developmental Level Information:
Motor Development Expectations for your Patient:
Play Activities recommended for your Patient
144
SOUTH PLAINS COLLEGE
NURSING PROCESS
Client’s Initials____________
Diagnosis ________________
Age _______ Rm__________
ANALYSIS
Problem/Nursing Diagnosis
Student______________________
Date________________________
Instructor____________________
PLAN
Goal Statements with
Outcome Criteria
IMPLEMENTATION
Nursing Orders
EVALUATION
Evaluative Outcome
Criteria
Scientific Rationale
145
Student Name:_____________________ Site: _________________ Date: _____________
S.P.C. RNSG 2462
PEDIATRIC CLINICAL PREPARATIONWORKSHEET
Patient Initial: __________
Vital Signs Norms: B.P.
**(For your patient’s age group)
Age
P.
lb.
kgs.
R.
T.
Date of Admission:
Surgical Procedures:
Admission Medical Diagnosis:
Diagnostic Procedures:
Additional diagnoses affecting this child:
Diet:
Pertinent Laboratory Data:
Allergies:
Activity:
IV Therapy:
Plan for the day: List treatments, procedures and current medications scheduled for your shift
(including times).
Medical Diagnosis: _________________________________________________________
Pathophysiology:
Clinical Manifestations: Underline signs and symptoms shown by the patient.
146
Erikson’s Developmental Level Information:
Piaget Developmental Level Information:
Motor Development Expectations for your Patient:
Play Activities recommended for your Patient
147
SOUTH PLAINS COLLEGE
NURSING PROCESS
Client’s Initials____________
Diagnosis ________________
Age _______ Rm__________
ANALYSIS
Problem/Nursing Diagnosis
Student______________________
Date________________________
Instructor____________________
PLAN
Goal Statements with
Outcome Criteria
IMPLEMENTATION
Nursing Orders
EVALUATION
Evaluative Outcome
Criteria
Scientific Rationale
148
Student Name:_____________________ Site: _________________ Date: _____________
S.P.C. RNSG 2462
PEDIATRIC CLINICAL PREPARATIONWORKSHEET
Patient Initial: __________
Vital Signs Norms: B.P.
**(For your patient’s age group)
Age
P.
lb.
kgs.
R.
T.
Date of Admission:
Surgical Procedures:
Admission Medical Diagnosis:
Diagnostic Procedures:
Additional diagnoses affecting this child:
Diet:
Pertinent Laboratory Data:
Allergies:
Activity:
IV Therapy:
Plan for the day: List treatments, procedures and current medications scheduled for your shift
(including times).
Medical Diagnosis: _________________________________________________________
Pathophysiology:
Clinical Manifestations: Underline signs and symptoms shown by the patient.
149
Erikson’s Developmental Level Information:
Piaget Developmental Level Information:
Motor Development Expectations for your Patient:
Play Activities recommended for your Patient
150
SOUTH PLAINS COLLEGE
NURSING PROCESS
Client’s Initials____________
Diagnosis ________________
Age _______ Rm__________
ANALYSIS
Problem/Nursing Diagnosis
Student______________________
Date________________________
Instructor____________________
PLAN
Goal Statements with
Outcome Criteria
IMPLEMENTATION
Nursing Orders
EVALUATION
Evaluative Outcome
Criteria
Scientific Rationale
151
Student Name:_____________________ Site: _________________ Date: _____________
S.P.C. RNSG 2462
PEDIATRIC CLINICAL PREPARATIONWORKSHEET
Patient Initial: __________
Vital Signs Norms: B.P.
**(For your patient’s age group)
Age
P.
lb.
kgs.
R.
T.
Date of Admission:
Surgical Procedures:
Admission Medical Diagnosis:
Diagnostic Procedures:
Additional diagnoses affecting this child:
Diet:
Pertinent Laboratory Data:
Allergies:
Activity:
IV Therapy:
Plan for the day: List treatments, procedures and current medications scheduled for your shift
(including times).
Medical Diagnosis: _________________________________________________________
Pathophysiology:
Clinical Manifestations: Underline signs and symptoms shown by the patient.
152
Erikson’s Developmental Level Information:
Piaget Developmental Level Information:
Motor Development Expectations for your Patient:
Play Activities recommended for your Patient
153
SOUTH PLAINS COLLEGE
NURSING PROCESS
Client’s Initials____________
Diagnosis ________________
Age _______ Rm__________
ANALYSIS
Problem/Nursing Diagnosis
Student______________________
Date________________________
Instructor____________________
PLAN
Goal Statements with
Outcome Criteria
IMPLEMENTATION
Nursing Orders
EVALUATION
Evaluative Outcome
Criteria
Scientific Rationale
154
Student Name:_____________________ Site: _________________ Date: _____________
S.P.C. RNSG 2462
PEDIATRIC CLINICAL PREPARATIONWORKSHEET
Patient Initial: __________
Vital Signs Norms: B.P.
**(For your patient’s age group)
Age
P.
lb.
kgs.
R.
T.
Date of Admission:
Surgical Procedures:
Admission Medical Diagnosis:
Diagnostic Procedures:
Additional diagnoses affecting this child:
Diet:
Pertinent Laboratory Data:
Allergies:
Activity:
IV Therapy:
Plan for the day: List treatments, procedures and current medications scheduled for your shift
(including times).
Medical Diagnosis: _________________________________________________________
Pathophysiology:
Clinical Manifestations: Underline signs and symptoms shown by the patient.
155
Erikson’s Developmental Level Information:
Piaget Developmental Level Information:
Motor Development Expectations for your Patient:
Play Activities recommended for your Patient
156
SOUTH PLAINS COLLEGE
NURSING PROCESS
Client’s Initials____________
Diagnosis ________________
Age _______ Rm__________
ANALYSIS
Problem/Nursing Diagnosis
Student______________________
Date________________________
Instructor____________________
PLAN
Goal Statements with
Outcome Criteria
IMPLEMENTATION
Nursing Orders
EVALUATION
Evaluative Outcome
Criteria
Scientific Rationale
157
Student Name:_____________________ Site: _________________ Date: _____________
S.P.C. RNSG 2462
PEDIATRIC CLINICAL PREPARATIONWORKSHEET
Patient Initial: __________
Vital Signs Norms: B.P.
**(For your patient’s age group)
Age
P.
lb.
kgs.
R.
T.
Date of Admission:
Surgical Procedures:
Admission Medical Diagnosis:
Diagnostic Procedures:
Additional diagnoses affecting this child:
Diet:
Pertinent Laboratory Data:
Allergies:
Activity:
IV Therapy:
Plan for the day: List treatments, procedures and current medications scheduled for your shift
(including times).
Medical Diagnosis: _________________________________________________________
Pathophysiology:
Clinical Manifestations: Underline signs and symptoms shown by the patient.
158
Erikson’s Developmental Level Information:
Piaget Developmental Level Information:
Motor Development Expectations for your Patient:
Play Activities recommended for your Patient
159
SOUTH PLAINS COLLEGE
NURSING PROCESS
Client’s Initials____________
Diagnosis ________________
Age _______ Rm__________
ANALYSIS
Problem/Nursing Diagnosis
Student______________________
Date________________________
Instructor____________________
PLAN
Goal Statements with
Outcome Criteria
IMPLEMENTATION
Nursing Orders
EVALUATION
Evaluative Outcome
Criteria
Scientific Rationale
160
Student Name:_____________________ Site: _________________ Date: _____________
S.P.C. RNSG 2462
PEDIATRIC CLINICAL PREPARATIONWORKSHEET
Patient Initial: __________
Vital Signs Norms: B.P.
**(For your patient’s age group)
Age
P.
lb.
kgs.
R.
T.
Date of Admission:
Surgical Procedures:
Admission Medical Diagnosis:
Diagnostic Procedures:
Additional diagnoses affecting this child:
Diet:
Pertinent Laboratory Data:
Allergies:
Activity:
IV Therapy:
Plan for the day: List treatments, procedures and current medications scheduled for your shift
(including times).
Medical Diagnosis: _________________________________________________________
Pathophysiology:
Clinical Manifestations: Underline signs and symptoms shown by the patient.
161
Erikson’s Developmental Level Information:
Piaget Developmental Level Information:
Motor Development Expectations for your Patient:
Play Activities recommended for your Patient
162
SOUTH PLAINS COLLEGE
NURSING PROCESS
Client’s Initials____________
Diagnosis ________________
Age _______ Rm__________
ANALYSIS
Problem/Nursing Diagnosis
Student______________________
Date________________________
Instructor____________________
PLAN
Goal Statements with
Outcome Criteria
IMPLEMENTATION
Nursing Orders
EVALUATION
Evaluative Outcome
Criteria
Scientific Rationale
163
Student Name:_____________________ Site: _________________ Date: _____________
S.P.C. RNSG 2462
PEDIATRIC CLINICAL PREPARATIONWORKSHEET
Patient Initial: __________
Vital Signs Norms: B.P.
**(For your patient’s age group)
Age
P.
lb.
kgs.
R.
T.
Date of Admission:
Surgical Procedures:
Admission Medical Diagnosis:
Diagnostic Procedures:
Additional diagnoses affecting this child:
Diet:
Pertinent Laboratory Data:
Allergies:
Activity:
IV Therapy:
Plan for the day: List treatments, procedures and current medications scheduled for your shift
(including times).
Medical Diagnosis: _________________________________________________________
Pathophysiology:
Clinical Manifestations: Underline signs and symptoms shown by the patient.
164
Erikson’s Developmental Level Information:
Piaget Developmental Level Information:
Motor Development Expectations for your Patient:
Play Activities recommended for your Patient
165
SOUTH PLAINS COLLEGE
NURSING PROCESS
Client’s Initials____________
Diagnosis ________________
Age _______ Rm__________
ANALYSIS
Problem/Nursing Diagnosis
Student______________________
Date________________________
Instructor____________________
PLAN
Goal Statements with
Outcome Criteria
IMPLEMENTATION
Nursing Orders
EVALUATION
Evaluative Outcome
Criteria
Scientific Rationale
166
Student Name:_____________________ Site: _________________ Date: _____________
S.P.C. RNSG 2462
PEDIATRIC CLINICAL PREPARATIONWORKSHEET
Patient Initial: __________
Vital Signs Norms: B.P.
**(For your patient’s age group)
Age
P.
lb.
kgs.
R.
T.
Date of Admission:
Surgical Procedures:
Admission Medical Diagnosis:
Diagnostic Procedures:
Additional diagnoses affecting this child:
Diet:
Pertinent Laboratory Data:
Allergies:
Activity:
IV Therapy:
Plan for the day: List treatments, procedures and current medications scheduled for your shift
(including times).
Medical Diagnosis: _________________________________________________________
Pathophysiology:
Clinical Manifestations: Underline signs and symptoms shown by the patient.
167
Erikson’s Developmental Level Information:
Piaget Developmental Level Information:
Motor Development Expectations for your Patient:
Play Activities recommended for your Patient
168
SOUTH PLAINS COLLEGE
NURSING PROCESS
Client’s Initials____________
Diagnosis ________________
Age _______ Rm__________
ANALYSIS
Problem/Nursing Diagnosis
Student______________________
Date________________________
Instructor____________________
PLAN
Goal Statements with
Outcome Criteria
IMPLEMENTATION
Nursing Orders
EVALUATION
Evaluative Outcome
Criteria
Scientific Rationale
169
Student Name:_____________________ Site: _________________ Date: _____________
S.P.C. RNSG 2462
PEDIATRIC CLINICAL PREPARATIONWORKSHEET
Patient Initial: __________
Vital Signs Norms: B.P.
**(For your patient’s age group)
Age
P.
lb.
kgs.
R.
T.
Date of Admission:
Surgical Procedures:
Admission Medical Diagnosis:
Diagnostic Procedures:
Additional diagnoses affecting this child:
Diet:
Pertinent Laboratory Data:
Allergies:
Activity:
IV Therapy:
Plan for the day: List treatments, procedures and current medications scheduled for your shift
(including times).
Medical Diagnosis: _________________________________________________________
Pathophysiology:
Clinical Manifestations: Underline signs and symptoms shown by the patient.
170
Erikson’s Developmental Level Information:
Piaget Developmental Level Information:
Motor Development Expectations for your Patient:
Play Activities recommended for your Patient
171
SOUTH PLAINS COLLEGE
NURSING PROCESS
Client’s Initials____________
Diagnosis ________________
Age _______ Rm__________
ANALYSIS
Problem/Nursing Diagnosis
Student______________________
Date________________________
Instructor____________________
PLAN
Goal Statements with
Outcome Criteria
IMPLEMENTATION
Nursing Orders
EVALUATION
Evaluative Outcome
Criteria
Scientific Rationale
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PEDIATRIC INTENSIVE CARE (PICU)
Clinical Preparation Requirements
You will not pick up a patient assignment the day before this rotation-you will be assigned to a
nurse when you arrive in PICU and will assist that TPCN as they deem appropriate and you feel
comfortable.
Did you do each of these BEFORE going to PICU?
_____ Review the clinical site tool objectives and site tool hints on WebCT
_____ Read the appropriate chapters in the Pediatrics textbook (Suggestion: respiratory, trauma,
assessment information).
_____ Read UMC “Pediatrics and PICU” orientation packet regarding PICU.
Bring these with you to PICU:
_____ Print a copy of the PICU site tool to bring to clinicals to guide information gathering.
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PEDIATRIC RELATED COMMUNITY EXPERIENCES
Clinical Preparation Requirements
You will be assigned a variety of clinical experiences throughout the semester. You should
complete the pediatric related community experience site tool for each place you go where you
care for Pediatric patients. Please refer to your clinical directory for specific information about
each site you are scheduled to go for rotations.
Did you do each of these BEFORE going to Pediatric Related Community Experiences?
_____ Review the site tool objectives and site tool hints on WebCT
_____ Read appropriate chapters in the Pediatrics textbook.
_____ Make sure you know the location of the clinic, etc.
Bring these with you to the location:
_____ Print a copy of the appropriate site tool found on WebCT to bring with you to help gather
the needed information.
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WOMAN’S HEALTH COMMUNITY EXPERIENCES
Clinical Preparation Requirements
You will be assigned a variety of clinical experiences throughout the semester. You should
complete the women’s health community experience site tool for each place you go where you
care for OB/GYN patients. Please refer to the clinical directory for specific information about
each site you are scheduled to go to rotations.
Did you do each of these BEFORE going to Women’s Health Community Experiences?
_____ Review the site tool objectives and site tool hints found on WebCT
_____ Review the Antepartal Study Guide for the Texas Tech OB Clinic.
_____ Read the appropriate chapters in the OB textbook.
_____ Make sure you know the location of the clinic, etc.
Bring these with you to the location:
_____ Print a copy of the appropriate site tool found on WebCT to bring with you to help gather
the needed information.
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Antepartal Study Guide
RNSG 2462
SOUTH PLAINS COLLEGE
ASSOCIATE DEGREE NURSING PROGRAM
ANTEPARTAL STUDY GUIDE
*This may be handwritten. If you write out only the answers without the questions, please attach
this study guide to your answers.
Please put the page numbers and the source by each answer.
Susan Bliss has one three-year-old child, lost a pregnancy at two months gestation, and another
at six months gestation. Her last L.M.P. was October 16. Mrs. Bliss has come to Southwest
Prenatal Clinic after missing two consecutive normal menses.
1. Mrs. Bliss is para__________gravida_______________________________.
2. Mrs. Bliss E.D.C. is __________. (Use Naegele's Rule and show your work.)
3. Describe the following physiologic changes, which occur during pregnancy and state the
cause when known:
a. Chadwick's Sign:
b. Hegar's Sign
c. Goodell's Sign
d. Describe the changes that occur in the Cardiovascular System during pregnancy in
relation to:
(1) Blood volume:
(2) Blood count:
(3) Cardiac size:
(4) Blood Pressure:
(5) Hgb & Hct - 1st trimester _______________, 2nd trimester _______________,
3rd trimester _______________.
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Appendix H/Antepartal Study Guide
RNSG 2462
e. Describe changes in the urinary tract during pregnancy in relation to:
(1) Frequency of urination is normal during what trimester(s) and abnormal during
what trimester(s)? Discuss the causes of frequency of urination.
(2) Why are pregnant women more susceptible to tract infections?
f. Describe changes in the breasts in relation to:
(1) Sensitivity:
(2) Pigmentation:
g. Describe changes of the skin of the pregnant woman and discuss the causes:
(1) Face:
(2) Abdomen:
4. When pregnancy is determined, laboratory tests are obtained during the initial prenatal
visit. List at least four.
a.
b.
c.
d.
5. Generally speaking, how often should a doctor see a prenatal patient?
a. First six months _____________________________________
b. Seventh and eighth months ____________________________
c. Last four weeks _____________________________________
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Appendix H/Antepartal Study Guide
RNSG 2462
6. Which three tests or measurements are routinely performed at each routine prenatal visit?
a. __________________________________________________
b. __________________________________________________
c. __________________________________________________
7. The height of the fundus is often used to assist in diagnosing E.D.C.
a. Size and weight of uterus before pregnancy:
b. The pregnant uterus is:
(1) at the level of the symphysis pubis at _____________________________________.
(2) at the level of the umbilicus at ___________________________________________.
(3) at the ensiform cartilage (xiphoid process) at _______________________________.
8. Explain when lightening occurs in the primipara, and when in the multipara.
9. Define quickening and tell when it normally occurs:
10. What are the positive signs of pregnancy?
11. Discuss the use of sonography (sonogram) during the antepartal period:
Early
Late
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Appendix H/Antepartal Study Guide
RNSG 2462
12. Explain hormonal sources and action during pregnancy of the following:
a.
b.
c.
d.
e.
f.
g.
h.
i.
F.S.H.
Estrogen
Progesterone
Relaxin
Prolactin
Oxytocin
H.C.G.
LH
HCS
13. The placenta is the major endocrine gland during pregnancy. List the hormones secreted by
the placenta.
14. What danger signals should be reported promptly to the physician by the prenatal patient?
a.
b.
c.
d.
e.
15. Discuss the feelings about sexuality and sexual intercourse the pregnant woman may have:
16. What instructions would you give Susan and her husband regarding sexual activity during
pregnancy?
179
Appendix H/Antepartal Study Guide
RNSG 2462
17. The pregnant woman often experiences minor discomforts. Discuss the possible
causes and state means by which they may be alleviated.
a. Nausea
b. Heartburn
c. Exercise
d. Constipation
e. Leg cramps
f. Hemorrhoids
g. Backache
h. Varicose veins
18. Discuss the emotional changes and feelings women experience during pregnancy.
19. Nutrition during pregnancy.
a. Mrs. Bliss weighs 132 lb. Her expected weight gain will be a total of __________
during first trimester; __________ during second trimester; and __________ during
third trimester.
b. The recommended daily allowance of calories during pregnancy is __________ Kcal
above the woman's usual allowance.
c. List substitutes for milk (calcium requirements).
(1)
(2)
(3)
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RNSG 2462 NURSING PROCESS GUIDELINES
This sheet contains helpful information to assist you in completing the
nursing processes for clinical rotations. You will complete 2 Pediatric
Processes; 1 Labor & Delivery Process; and 1 Postpartum Processes.
The grades for these 4 processes will be averaged and count for 20 % of the
RNSG 2462 course grade. (If you cannot complete a process due to an
absence, your makeup assignment grade will substitute for the missed process
grade.)
Grading Breakdown is:
Diagnosis
20 pts.
Plan
10 pts.
Implementation
30 pts.
Rationale
20 pts.
Evaluation
20 pts.
Total Possible Pts. 100 pts.
Diagnosis
Must be stated in proper format. You may use either nursing diagnoses
or collaborative problems. You must make either a one-part, two-part, or
three-part statement. (i.e. a three part statement will include: problem related
to etiology or contributing factors as evidenced by symptoms and /or signs).
Diagnoses for this course do not have to be Nanda approved; you can be
creative as long as you put the diagnosis in the proper format.
You can only use a diagnosis once on Pediatric processes; therefore
you will have to work up 2 different diagnoses for your processes.
***If a pediatric diagnosis is repeated or if their interventions are
mostly the same, then you will be given a 0 for the repeated process.
Plan
One broad goal for your diagnosis. Be sure to include the timeframe in
which you expect to accomplish the goal. You must include outcome criteria
that can be measured.
Implementation
181
You should include as many nursing orders as you need to accomplish
your goal. You need to number each order. You may use processes from
textbooks, BUT you must personalize them for your patient.
( i.e. “Monitor I & O” will have to include the calculations for expected or
desired intake and output for your pediatric patients based on weight and the
formula in the textbook. Another example is “Administer antibiotics in a
timely manner” you must state what was ordered for your patient including
dose, route and dose schedule in order to personalize this for your patient.)
Scientific Rationale
Every nursing order must have a scientific rationale. Number each
rationale to match your nursing order. You do not have to list a source if you
can state the scientific rationale from the knowledge you have gained during
previous semesters, BUT these should state the reason for the order (This
should answer the question “Why do we do this order”)
Evaluation
This should be a 3 part statement including:
1. whether the goal was met, unmet, or partially met
2. then back this statement up with how each order was accomplished
or not accomplished
3. then state whether you need to continue and re-evaluate
periodically, revise or discontinue the goal
 If you used any resources (textbooks, websites, etc.) to help you to
complete the process, please state them at the bottom of your process
sheet in APA format.
 Points may be deducted for lack of neatness.
 Points will be deducted if not turned in when due.
 A zero will be given on any process in which the diagnosis is repeated
for that area. (Be aware that if the interventions for a diagnosis are
mostly the same then that will be counted as the same diagnosis) If you
have any concerns regarding this, please ask the faculty in that clinical
area.
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Course Grade Worksheet
RNSG 2462
NURSINGCARE OF THE
CHILBEARING AND CHILDREARING FAMILY
STUDENT NAME: __________________________________________________________________
Grade
OB Database
__________
X .20 = _____________
Pedi Database
__________
X .20 = _____________
Teaching Project or
Article Presentation
__________
X .20= _____________
Stages of Labor
__________
X .20 = ____________
Nursing Processes:
Average of Nursing
Process Grades
#1
#2
Grade
___________
___________
#3
___________
#4
___________
=
___________ X .20 = ____________
Total = _____________must be 77 or
Higher
77% of site tools scores are 2 or above
P
F
(circle one)
All starred and lettered objective on the final clinical evaluation tool are
Scored 2 or above
P
F
(circle one)
FINAL CLINICAL GRADE:
P
F
(circle one)
183