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OB ClinicalAssignment PacketNUR350:Obstetrical (OB) NursingPreparation for OB Clinical:The OB Preparation Packet (which will require viewing the OB SIM video to complete it) must be completed by the end of week 1.Will be available to view/download within (in NUR350) and the Simulation Google Classroom as of Week 11, and on Blackboard on Day 1/ Week 1 of the quarter.Students will need to arrive at clinical with: 1. OB Clinical Packet2. OB Preparation Packet (completed) 3. OB Assignment Packet (not completed, since it will be completed during the clinical)4. Completed set of Med Cards (can convert the med log from the OB Preparation Packet into 3x5 cards); placing a ring through the cards makes them easier to use, if possible.Instructors will check students off for these items when they arrive at clinical on Day 1; lack of completion of the OB Preparation Packet will warrant a fail.During clinical, complete the OB Care Plan and Newborn Assessment:Students must complete the OB Assignment Packet, which includes a comprehensive OB Nursing Care Plan and a hands-on Newborn Assessment. A grade of 78% or higher is required on each to pass the course. The care plan is written on one patient (mom or newborn) and includes three nursing diagnoses, as well as goals, interventions and rationales describing how the interventions support the goals. The OB care plan will be written for a patient cared for in the clinical setting and graded by the DCN Clinical Instructor. The newborn assessment will also be graded by the DCN Clinical Instructor. If your clinical rotation has a preceptor or clinical scholar (hospital employee), the assignments will be graded by the OB Didactic Professor. *Once your assignments are graded please upload the assignments and the rubrics to Blackboard in a timely fashion.*OB Nursing Care PlanStudent name_______________________________________________________ Cohort _______Patient identifier (initials), age, G/P ________________________________________________________ Relevant Antepartum/Intrapartum History (comprehensive) _________________________________________________________________________________________________________________________Current Labor/PP/NB Status (provide brief write-up of status) _______________________________________________________________________________________________________________________Assessment data(relevant per nursing diagnosis)Nursing Dx #1 (PES)SMART Goal (Pt will…)Interventions (RN will…)Rationale (how do interventions promote goal?)Evaluation (met/not met AEB, continuation plan)1.2.3.1.2.3.Nursing Dx #2 (PES)SMART GoalInterventionsRationaleEvaluation1.2.3.1.2.3.Nursing Dx #3 (PES)SMART GoalInterventionsRationaleEvaluation1.2.3.1.2.3.Rubric for OB Nursing Care Plans Student Name: Cohort:Grade Awarded for Assignment:*Please use this rubric as a guide when formulating your care plan. Use information from the patient, the chart, and your hands-on assessment to create a personalized care plan for each patient. Listed below are the criteria that will be used to grade your care plans.* MUST BE TYPE-WRITTENCriteria4Excellent>90%of criteria met3Very Good80-90% met2Good70-80% met1Fair60-70% met0NotAcceptable< 60% metPatient InformationPatient identifier, age and G/P is includedComprehensive antepartum/ intrapartum information, including complications, is includedCurrent Labor/ PP/ NB status (brief write-up) is providedAssessment Data: Should include data such as vital signs, lab values, physical exam findings, assessment of attachment and bonding, breastfeeding, etc.Chosen assessment data shows an understanding of what to include as it pertains to the nursing diagnosisAssessment (comprehensively, in the entire care plan) reflects physiological, psychological, sociocultural, spiritual, and economic data, as well as other lifestyle factorsCriteria4Excellent3Very Good2Good1Fair0NotAcceptableNursing Diagnosis StatementsThree [3] Nursing Diagnoses are presented; two medical/ physical and one psychosocialNANDA approved diagnoses are usedWritten in proper format (PES)Relevant to assigned patient per assessmentListed from highest to lowest priority and actual problems are listed before “risk for” problemsPlan: Goal Statements One goal is written for each nursing diagnosisGoals are patient-centered [PC] (Pt. will...)Goals are Specific, Measurable, Attainable, Realistic, Time-specific [SMART]Nursing Interventions Three interventions are presented per goal, stated as instructions (“RN will”)Are specific (what/ when/ how often/ how much)Are related to goalsAre prioritized, reasonable, and achievableRationale for each intervention cited, using APA formatCriteria4Excellent3Very Good2Good1Fair0NotAcceptableEvaluation and Revision of PlanEvaluation statements (one per goal) state whether goal was met/ partially met/ not metEvaluations directly reflect goal statementsA continuation of care plan is included (e.g. ongoing monitoring, education at the time of discharge, etc.)GeneralCare plan is readable, makes sense, is practical and realistic; must be typed!Spelling and grammar are correctRubric is attached to care planScore: ____________/100 (Maximum Score= 100 points) = _________%______________________________________________ _________________ Clinical Instructor/RN Signature Date*Students: Please attach this rubric to your OB Nursing Care Plan when you submit it for grading*Newborn AssessmentStudent name _____________________________________________ Cohort_________________Newborn Identifier and Birthdate:Time of delivery:APGAR 1/5/10Birth weight _______gramsCurrent weight _____gramsLength:_______cmHead circumference:______cmChest circumference:_________ cmGestational age:(Circle one)AGA SGA LGAMaternal age ____________ G___/ P________ Blood Type _______ GBS Status ______________Labor Hx: Onset/ total hrs of labor _______________________________________________________AROM/ SROM time___________ Meconium stained fluid or terminal meconium? ______________Maternal medications/ analgesia _________________________________________________________Antepartum/ Intrapartum complications ___________________________________________________Delivery: NSVD/ time __________________ Vacuum/forceps _______________________________ C/S: Planned/ Urgent/ Emergent Reason _____________________________________Cord clamped at __________min. Skin-to-skin _______________minNewborn resuscitation required? _________________________________________________________Newborn blood sugar (in preterm, postterm SGA, LGA, maternal diabetic, other), give level __________Bilirubin (TcB or TSB) ___________ CCHD result ____________ Hearing screen result ____________First feeding @ ____________ min/ hr of life Type of feeding (breast/ bottle) __________________ Complete the following by circling or highlighting exam findings, include any deviations from normal.CATEGORYOBSERVATIONSCOMMENTS (include abnormal findings)General AppearanceColor: pink/ pale/ acrocyanosis/ jaundicedCry: strong/ weak/ high-pitchedTone: normal (flexed)/ hypotonic/ hypertonicSkinPeeling/ rash/ bruising/ vernix/ petechiae/ mongolian spotsHeadMolding/ caput/ open flat fontanels/ cephalhematomaEyesClear/ discharge/ jaundice/ hemorrhageENTIntact palate/ normal ear setting/ patent nares/ nasal flaringAirway patent? Upper airway congestion?ChestSymmetrical/ clavicle (intact)/ fractured (L R)Nipple placement/ breast tissueChest movement symmetrical/ ribs symmetricalRespiratoryRR ____Clear/ equal bilaterally/ retractions/ grunting/ coarse breath sounds (eg, crackles)/ apneic episodesHeartHR _______Regular rate/ peripheral pulses bilaterally (femoral)/ murmur/ PMIAbdomenSoft/ distended/ bowel sounds (present, diminished, absent), umbilical vessels ____, cord clampGenitaliaMale/ female/ ambiguousTestes descended (R, L), undescendedFemale: pseudomenstruation/ discharge/ appearanceAnusPlacement normal/ meconium (present/absent)Anal wink?SpineGluteal folds (equal/ unequal)/ pilonidal dimpleSpine straight/ curvedExtremitiesSymmetrical movement/ polydactyly/ syndactylyFlexion (range of motion)/ muscle toneReflexes notedMoro/ grasp/ suck/ rooting/ swallow/ babinski/ tonic neck/ trunk incurvation/ stepStateQuiet awake/ alert/ active/ sleeping/ cryingNote other relevant care data, including maternal/infant interactions: _____________________________________________________________________________________Complete the following newborn pain assessment by circling or highlighting findings.Rubric for Newborn Assessment Student Name: Cohort:Grade Awarded for Assignment:Criteria10Excellent>90% of criteria met9Very Good80-90% met8Good70-80% met7Fair60-70% met6Poor< 60% met5NotAcceptable< 50% metApgar score noted/ measurements and gestational age accurately notedNewborn testing accurately noted (blood sugar, TcB/ TSB, CCHD, hearing)Maternal data recorded accuratelyData relevant to delivery and associated events or any antepartum/intrapartum complicationsLabor history, including duration ROM and mode of delivery notedMedications in labor notedFeeding information recordedHead-to-toe assessment accurately documentedNIPS score accurately documentedStudent observed performing exam and recording dataClinical Instructor verifies observation of Newborn exam: Date___________________________________________________ ____________________Score: ________/100 (Maximum Score= 100 points) = ___________%*Students: Please attach this rubric to your Newborn Assessment when you submit it for grading*1982817-43468600Brief Head-to-Toe AssessmentThis Brief Head-to-Toe assessment guide is a summary of the most common assessments done by nurses in the acute care setting. Nursing students need to practice these often to develop their own style of a thorough yet quick assessment of the patient’s status. Once the BHT is completed, if findings are abnormal, nurses must decide and prioritize their next course of action through following the remaining steps of the nursing process. **All palpation and auscultation must be done directly on the skin** Please remember this assessment is only for reflection and is not to substitute a full head to toe as appropriate for your patient. Pregnant women have additional assessment needs.As you enter the patient’s room:SWIPE – See Universal Safety ProtocolObserve patient & their response as you perform SWIPE as this initial communication will help you assess the patient’s neuro status, thought processes, speech, etc.Vital Signs: T: __________ P: __________ R: __________ BP: __________ (manual) SpO2: ______ O2 delivery: ____ Pain: (OPQRSTU) ____________________________________________________________________General Survey: Neuro: appearance, behavior, hygiene, affect, mood, eye contactOverall skin color; Breathing effort (rhythm & depth)Head:Level of Consciousness: Alertness and Orientation to person, place, time, situation; If altered, use GCSHEENT: symmetry/movement, deformities, skin integrity; PERRLA (Perform associated Cranial Nerve assessments as indicated)Thorax:Respiratory: inspect chest for shape and respiratory effort; auscultate anterior/posterior lung soundsCardiac: auscultate APEtoMan (S3/S4 sounds? murmurs?); auscultate apical HR for 1 minuteGastrointestinal: inspect abdominal contour; auscultate bowel sounds in all 4 quads; light palpation, last BMGenitourinary: consider ability to void, incontinence, indwelling catheter placement and conditionUpper Extremities: (anterior/posterior)Skin: Inspect for overall skin color and intactness; IV lines (peripheral); fingernail shape/conditionCardiac: Inspect color, Palpate for temperature, edema, radial pulses & capillary refill on fingers Musculoskeletal/Neuro: Inspect for deformities; Assess shoulder shrug, arm & grip strength and sensation bilaterally Lower extremities: (anterior/posterior)Skin: Inspect for overall skin color and intactness Cardiac: Inspect color, Palpate for temperature, edema, pedal pulses & capillary refill on toes Musculoskeletal/Neuro: Inspect for deformities, check foot pushes, leg lifts, and sensation bilaterally; May assess gait with the Get Up and Go testDCN Universal Safety Protocol SWIPE In State your name & title/ Scan environment Wash hands Identify patient (name/DOB) Provide privacy Explain procedure/Ask Permission BRowN COW Out Bed low Rails up (cannot restrain) Needed items in reach Call light in reach Open privacy curtain Wash hands ................
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