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Patient Name: Maria R.
Age: 23
Gravida/Para (G/P): G1P1 (primigravida)
Hospitalized for: Spontaneous vaginal delivery at 39 weeks
History/Conditions:
Anemia in pregnancy (Hgb 9.5 g/dL on admission)
Prolonged second stage of labor (3.5 hours)
Mild gestational hypertension diagnosed at 36 weeks (BP averaging 140/90)
No significant past medical history
Delivery Details:
Delivered a healthy baby boy, 7 lb 9 oz, at 8:20 AM.
Third stage of labor lasted 20 minutes.
Moderate vaginal tear requiring suturing.
Blood loss estimated at 800 mL (higher than normal).
Postpartum Nursing Unit Findings:
Fundus boggy, deviated to the right.
Heavy vaginal bleeding with large clots noted on pad checks.
Patient reports feeling dizzy, weak, and lightheaded upon sitting up.
Vital signs:
BP 90/58 mmHg
HR 118 bpm
Temp 99.2°F
Lochia: Heavy, bright red
Hgb post-delivery: 7.8 g/dL (down from 9.5 g/dL)
Interventions:
Fundal massage performed — uterus responded but remained soft after brief improvement.
Straight catheterization performed — drained 450 mL urine (bladder distention contributing to atony).
Administered IV oxytocin per protocol.
Blood type and cross-match sent.
1 unit packed RBCs ordered.
Emotional support provided; patient tearful and anxious, reporting fear about her bleeding.
Additional Anticipated/Postpartum Unit Findings:
Fatigue and pallor (due to anemia and blood loss)
Difficulty initiating breastfeeding due to exhaustion
Anxiety about newborn care and physical recovery
Close monitoring for postpartum depression risk factors
Possible delayed ambulation related to dizziness and weakness
Hematoma assessment at the perineal repair site
Clinical Judgement Plan
Instructor:
DATE Care Provided and UNIT:
Student Name
Clinical Judgement Plan
West Coast University
Professor Name
Date
OB History
GTPAL:
Prenatal Panel
Blood Type/Rh: GBS: Hep B: HIV: Rubella: RPR: Chlamydia: Gonorrhea: HSV:
Delivery Summary
Gestational age:
Delivery Type:
Delivery Time:
Postpartum Day: Placenta Delivery Time: Lacerations/Episiotomy: QBL: APGAR Score:
ROM type and time:
Complications:
Social History
Patient Information
Patient Initials:
Admission Date:
Chief Complaint:
Age & Gender:
Admission Weight:
Allergies:
Code Status:
Living Will/ DPOA:
History of Present Illness (HPI)
Admitting Diagnosis & Pathophysiology
Medical History & Pathophysiology
Surgical History & Pathophysiology
Erikson’s Developmental Stage Related to Patient (1) *List and discuss specific stage (based on objective assessment)
Social Determinants of Health
Ethnicity
Occupation
Religion
Family support
Insurance
3 Psychosocial Considerations/Concerns
Teaching Assessment and Client Education
Discharge Planning
Interprofessional Consults and Multidisciplinary Plan
Lab Tests with Values
(Include normal ranges, dates, and rationales of abnormal results)
|
Lab Tests or Diagnostic Tests |
Normal Ranges |
Admission Lab Values |
Current Lab Values |
Explain Abnormal Results R/T Your Patient (USE additional pages at the end of template WHEN NEEDED) |
Diagnostics
(3) Relevant Diagnostic Procedures with Results
(2) Medications
Medication Name
Include Generic name, Trade name, and Medication Class.
Include OTC, herbal (non-pharmacological items) and PRN medications given during clinical
Dose
Route
Frequency
Purpose of Medication for Your Patient
Mechanism of Action
Side Effects/
Adverse Reactions
Nursing Considerations Specific to Your Patient/Teaching
Physical Assessment/Review of Systems
Postpartum BUBBLE Assessment
Time of care: ____________________________________
Labor Assessment
Episiotomy/Laceration/
Incision
Vital Signs/Height/Weight
Temp:
HR:
BP:
RR:
SpO2:
Pain:
Height:
Weight:
Bowel
Bladder
Uterus
Breasts
Respiratory
Cardiovascular
Neurological
Emotional
DVT
Lochia
Time of care: ____________________________________
HEENT
Psychosocial
Hydration/Nutrition
Vital Signs/Height/Weight
Temp:
HR:
BP:
RR:
SpO2:
Pain:
Height:
Weight:
Genitourinary (GU)
Vaginal Exam/Leopold’s
Lines/Drains/Tubes
Gastrointestinal (GI)
Safety
Respiratory
Cardiovascular
Neurological
Musculoskeletal and Activity
Integumentary
Endocrine
Responding
Observation
Interpreting
Implement
Planning
Analysis
Assessment
Take Action
Generate Solutions
Prioritize Hypotheses
Analyze Cues
Recognize Cues
Evaluate
Evaluation
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