Postpartum Care Evaluation

Name: Date:
Resource Nurse:  

 

 

Note: Have your resource nurse complete this form. Then submit to instructor at post conference.

Skill Performed Independently Performed with Assistance Had opportunity: Unable to perform Not observed
Asks appropriate questions
        
Follows directions
        
Seeks assistance when appropriate        
Admits a postpartum patient        
Completes a physical assessment        
Completes a fundal assessment        
Completes a lochia assessment        
Assesses perineum
        
Assesses breasts        
Assists with breast feeding        
Assess abdominal incision        
Instructs patient in perineal hygiene        
Instructs patient in post-op care
        
Completes a pain assessment        
Administers medications        
Completes a chart note        
Assess parent/child interactions        
Performs patient teaching        
Assists with patient discharge
        
Makes an appropriate referral        
Gives report        
Respects patient confidentiality        
Provides care for multiple patients        
Uses universal precautions        
Other        

 

 

Postpartum Database

Patient Information

Age:

G:

TPAL:

Living Children:

Feeding Type:

Delivery Date:

Delivery Time:

Delivery Type:

Days postpartum

Allergies:

 

Significant L&D or PN History (including amt of PN care):

 

Shift Report or Chart Information:

VS

 

 

IV: #

Credit:

Intake:

Nutrition:

Output:

 

Fundus location:

Fundus consistency:

Lochia: color and amount:

 

Lab Results:

RH Type:

Rubella:

Hep B:

Syphilis:

TB:

 

STIs:

Other:

Medications Prescribed and time to be given or Pt is taking (i.e. botanicals):

 

Health Needs: Psychosocial and physical. Include Pain assessment. Consider pt history!

 

 

My Assessment:

Time:

IV#

Amt. in Bag now:

Intake:

Output:

VS:

Heart:

Lungs:

Breasts:

Nipples:

Fundus consistency:

Fundus Location:

Incision:

Episiotomy:

Hemorrhoids:

Bladder:

Bowels:

Legs:

Nutrition:

Activity:

Interactions with newborn:

 

Medications Prescribed and time to be given or Pt is taking (i.e. botanicals): Indicate which were given.

 

Health Needs: Psychosocial and physical: Include Pain assessment, social support, hygiene, ambulation

 

 

Keystone Issue Clinical Journal:

1. What is your keystone nursing diagnosis for this patient (focusing on this diagnosis will assist in resolving other diagnoses) and briefly discuss how you chose this diagnosis:

2. What was the patient's present state and desired or achieved outcome state (which is based on your goal and the patient's goal):

3. What clinical reasoning skills did you use to work towards achieving the outcome state? Clinical reasoning requires knowledge, collecting data, solving problems by making decisions, judgment, providing quality interventions and evaluation of those interventions.

4.Complex Adaptive Systems (CAS): Was this keystone issue Simple, Complicated or Complex? Briefly explain your insights.