L & D worksheet for new grad.

Published

Hi! I'm a new graduate nurse and just began orientation for my new position in labor and delivery. I would love to have some sort of organizational tool ("brain")to help me with patient care. I realize this must be hard to do in this department, but perhaps some of you might have some you may be willing to share?? Any suggestions would be greatly appreciated. Thanks so much!!

Up Vote Up Vote ×
Specializes in OB.

Hello.

I don't have a worksheet per se but there are the things I want to know when I come on for a shift.

G's and P's

allergies

How many weeks is my pt. if preterm, any antibiotics ordered?

Bloodtype. If rh negative did she receive rhogam

gbs status. If positive how many doses has she received

rubella status

Other labs: Hep B, HIV, HSV, G/C

Membranes: intact? ruptured? If ruptured how long? Has she had a temp?

BP: WNLs?

If an induction, why is she being induced?

Contraction pattern/fetal heart rate

How dilated is she?

This is very basic but I hope this helps! I have been an L&D nurse for about nine months now. I remember how I felt when I first started. We do around 10,000 deliveries a year and it's pretty much a baptism by fire when you first start. Just remember to ask lots of questions and hang it there, and trust me it gets better. Feel free to PM whenever if you need to.

Up Vote Up Vote ×
Specializes in Pediatrics, ER.

Quick question. I'm not an OB nurse (hoping!) so my knowledge is a bit limited. Why do you start antibiotics if a mom is preterm? Is it just if she's preterm, or if she's preterm with prolonged PROM?

Up Vote Up Vote ×
Quick question. I'm not an OB nurse (hoping!) so my knowledge is a bit limited. Why do you start antibiotics if a mom is preterm? Is it just if she's preterm, or if she's preterm with prolonged PROM?

When a patient is preterm, they have an unknown GBS (group B strep) status. This test is usually done around 36 weeks gestation. With a pre-termer you would treat prophylactic. I am assuming that is what was meant by that. Feel free to correct me if I am wrong. :)

Up Vote Up Vote ×
Specializes in Women's Services.

I made this "brain" working with mother/baby couplets. Hopefully you can copy and paste it into a works document to see how it is supposed to look. The Mom's info is at the top and the baby's is at the bottom. I write information from report on the back of my sheet. I put the meds on the front left side, under the baby info. The "F" = feeding, "V" = voids and the "S" = stools

Rm______ Name________________________ Age_____MD__________________Allergies____________Wks__________

SVD or C/S Date______Time________ G_____P_____A_____Peri_________________ TopicalsSitzAM Labs?___

Bld Type______ GBS _____ Tx _________Rub____ Fundus________Lochia_________Pain________Diet______________

SB_______PPD_______ Flu________ Adacel_______Pneumo_______ Chart Audit___Teaching IV___________________________________Meds________________________________Incision_____________________

2000 (8)Pain______ Update/Needs _____________________________________________________________________

0000 Pain______ Update/Needs ____________________________________________________________________

0400 Pain______ Update/Needs __________________________________________________________________________

0600 Pain______ Update/Needs __________________________________________________________________________

　

Ped___________Sex______Wt___________Length Hep B__Eyes & Thi___IDHUGS______

HS R-____ L-____ PM WgtCirc?_______ Chart Audit____PKU_____ APGARS______

TCB: 24 hr______________zone 48hr or d/c______________zone Weight:Bath: __

Breast or Bottle Last feed: time__________minutes or amt________________Voided?____ Stooled?____

(Temp 97.5 - 99.5 Resp 30 - 60 HR 110 - 160)

2000 F________________ V ______________ S _______________ Update_______________VS______________________

2200 F________________ V ______________ S _______________ Update_______________________________________

0000 F________________ V ______________ S _______________ Update_______________VS_____________________

0200 F________________ V ______________ S _______________ Update_______________________________________

0400 F________________ V ______________ S _______________ Update____________________________________

0600 F________________ V ______________ S _______________ Update_______________________________________

Report received from:____________________________________________________________________________________

　

　

　

　

Up Vote Up Vote ×
+ Join the Discussion