Clinical Judgment Plan of Care Template for
Intrapartum Care (NURS301).
Clinical Judgement Plan of Care
Maternal-Child Nursing (Chamberlain University)
Studocu is not sponsored or endorsed by any college or university
Downloaded by dan wasilwa
, Relearning: Clinical Judgment Plan of Care Template
Student Name: Lucy Lu Date of Admission: 04/20/2024
Client Initials: AS Date of Care: 04/20/2024
Age/DOB: 19 y/o Admitting Diagnosis: Intrapartum Care
Allergies: NKDA Comorbidities: NA
BSA/BMI: NA Code Status:FULL Planned Treatments/Procedures: pain management and
monitoring
Nursing and HCP Collaborative Plan for Care: Include a description of priority client specific information, nursing actionsnd
provider
orders
Cultural/Spiritual: Health Promotion/Development:
No information related to culture presented
Pt education on stress and
Neurological/Cognition/Coping/Adaptation/Function: pain
A&Ox 4, pt mood appropriate to situation Infection/Immunity/Inflammation:
Nutrition/Elimination: N/a
Small amounts of lochia rubra Mobility:
noted Fluid/Electrolytes/Acid-
Base: Stand by assist
Pain/Comfort/Tissue Integrity:
nA
Gas Pain 8/10
Exchange/Perfusion: na Safety:
Fall/slip precautions in bathtub
Glucose Regulation:
N/A Other:
START of Shift (CJSim™) Priorities (Complete after receiving REPORT AND reviewing the EHR connected to phase
1/Question 1 section)
Generate Solutions &
Recognize & Analyze Prioritize Hypotheses Evaluate Outcomes
Take
Cues
Actions
Priority Hypotheses for Priority Priority
Priority
Assessments/Cues Nursing Care Interventions/Actions Teaching/Discharge
Needs
1. Educate pt on
1. Keep monitoring
1. Moderate variability 1. Normal fhr breastfeeding
techniques
2. Be ready for delivery
2. Pressure on rectum 2. This means time to push
2. Educate pt on
3. Check if there is any pain doctors visits and
3. Pain 8/10 3. This is due to contractions
meds prescribed or when to go
epidural
3. Educate pt on pain control
Priority Laboratory Priority Actual & Priority
Tests/ Priority Medications
Potential Collaborati
Diagnostic Cues Complications/Cues ve Actions
1. Potential fundus can
be boggy and have
1. No medication
1. FHR monitoring excessive bleeding
info available 1. Pediatrician
2. CBC 2. Placenta can leave
2. No info available 2. Nurse midwife
fragments causing
3. N/A infection
3. No info available 3. RN
3. Bathtub delivery can
cause infection/drowning
1
Relearning Clinical Judgment Plan of Care Template-Sept2 023 v1.1
Intrapartum Care (NURS301).
Clinical Judgement Plan of Care
Maternal-Child Nursing (Chamberlain University)
Studocu is not sponsored or endorsed by any college or university
Downloaded by dan wasilwa
, Relearning: Clinical Judgment Plan of Care Template
Student Name: Lucy Lu Date of Admission: 04/20/2024
Client Initials: AS Date of Care: 04/20/2024
Age/DOB: 19 y/o Admitting Diagnosis: Intrapartum Care
Allergies: NKDA Comorbidities: NA
BSA/BMI: NA Code Status:FULL Planned Treatments/Procedures: pain management and
monitoring
Nursing and HCP Collaborative Plan for Care: Include a description of priority client specific information, nursing actionsnd
provider
orders
Cultural/Spiritual: Health Promotion/Development:
No information related to culture presented
Pt education on stress and
Neurological/Cognition/Coping/Adaptation/Function: pain
A&Ox 4, pt mood appropriate to situation Infection/Immunity/Inflammation:
Nutrition/Elimination: N/a
Small amounts of lochia rubra Mobility:
noted Fluid/Electrolytes/Acid-
Base: Stand by assist
Pain/Comfort/Tissue Integrity:
nA
Gas Pain 8/10
Exchange/Perfusion: na Safety:
Fall/slip precautions in bathtub
Glucose Regulation:
N/A Other:
START of Shift (CJSim™) Priorities (Complete after receiving REPORT AND reviewing the EHR connected to phase
1/Question 1 section)
Generate Solutions &
Recognize & Analyze Prioritize Hypotheses Evaluate Outcomes
Take
Cues
Actions
Priority Hypotheses for Priority Priority
Priority
Assessments/Cues Nursing Care Interventions/Actions Teaching/Discharge
Needs
1. Educate pt on
1. Keep monitoring
1. Moderate variability 1. Normal fhr breastfeeding
techniques
2. Be ready for delivery
2. Pressure on rectum 2. This means time to push
2. Educate pt on
3. Check if there is any pain doctors visits and
3. Pain 8/10 3. This is due to contractions
meds prescribed or when to go
epidural
3. Educate pt on pain control
Priority Laboratory Priority Actual & Priority
Tests/ Priority Medications
Potential Collaborati
Diagnostic Cues Complications/Cues ve Actions
1. Potential fundus can
be boggy and have
1. No medication
1. FHR monitoring excessive bleeding
info available 1. Pediatrician
2. CBC 2. Placenta can leave
2. No info available 2. Nurse midwife
fragments causing
3. N/A infection
3. No info available 3. RN
3. Bathtub delivery can
cause infection/drowning
1
Relearning Clinical Judgment Plan of Care Template-Sept2 023 v1.1
