L_x_D_Clinical_Log_2 - L D Log Pg 1 of 7 Clinical Date San...

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L & D Log: Pg. 1 of 7 San Jose State University School of Nursing NURS 146B LABOR & DELIVERY CLINICAL LOG PART A: Patient History List complications of previous pregnancies and deliveries: _________________________________________________ ________________________________________________________________________________________________ List all complications and risk factors from H&P and/or L&D summary: ________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Does length of time between ROM & delivery put client at risk for complications? If yes, what kind of risk? ____________ ________________________________________________________________________________________________ List medications taken during pregnancy: _______________________________________________________________ Delivery Information Summary: SAN JOSE STATE UNIVERSITY SCHOOL OF NURSING NURS146B Log Part B: Labor and Delivery Assessment Worksheet Date of experience: ________________ Student’s Name: _____________________________ 5/4/08 DG adapted from AB Clinical Date: Student: Maternal Information Infant Information Initials: Age: Sex: DOB: Allergies: Weight: Time of birth: Language: Eng Span Other OFC: cm. G P Apgars: 1min: 5 min: 10 min: Blood Type: Rh: Gestational Age: VDRL/RPR: HbsAg: B Strep: Admission Vital signs: Rubella: PPD: Chlamydia: Temp: P: R: GC: CXR: Recent vital signs: Ethnicity: Religion: Birthplace: Temp. P: R: Circle: NSVD VBAC VACUUM FORCEPS C-SECTION EBL: Reason for C-Section: FTP CPD FD RPT Other: INTACT EPISIOTOMY LACERATION 1 st 2 nd 3 rd 4 th degree ARMOM or SROM Date: Time: Clear? MECONIUM: (type): none thin mod thick Foul Smelling? Time elapsed between ROM & delivery? NUCAL CORD: X or N/A LAB VALUES: Admission or prenatal Hgb/HTC:_________ Date:_______ Smoking/ETOH Mother FOB What labs were ordered postpartum? Maternal street drugs: Y N Time & Results: Marital Status: Teen S M W D Client lives with:
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L & D Log: Pg. 2 of 7
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