TITLE: GUIDELINE FOR COMPLETION OF THE OBSTETRICAL COLLABORATIVE PLAN OF CARE

INSTRUCTIONS:  This guideline is used in conjunction with the Maternal/Infant Division Documentation Policy.

The Obstetrical Collaborative Plan of Care is to be initiated when the pregnant patient is admitted to the hospital. If the patient is transferred from the Women’s Health Unit or the Mother/Baby Unit back to Labor and Delivery, the form should be included in the chart so that the Labor and Delivery personnel may have access for documentation.

1.     Patient identification
2.     Enter date and initials of health care worker identifying problem.
3.     Mark the appropriate box and enter date and initials.
        For any "No" RESPONSES, explain in nursing or focus note.
4.     Enter the date of post anesthesia recovery.
5.     Enter the recovery room admit time.
6.     Enter the recovery room discharge time.
7-9. To be used if the patient has a procedure that requires a second post-anesthesia     recovery time.
10-19. Use the following post anesthesia recovery score to complete on admission (10-14) and discharge (15-19).

Activity:

2 = Able to move 4 extremities voluntarily or on command
1 = Able to move 2 extremities voluntarily or on command
0 = Able to move 0 extremities voluntarily or on command

RESPIRATION:

2 = Able to deep breathe and cough freely
1 = Dyspnea or limited breathing
0 = Apnea

CIRCULATION:

2 = BP ± 20 of preanesthesia level
1 = BP ± 20 - 50 of preanesthesia level
0 = BP ± 50 of preanesthesia level

COLOR:

2 = Pink
1 = Pale, dusky, blotchy, jaundiced, other
0 - Cyanotic

CONSCIOUSNESS:

2 = Fully awake
1 = Arousable on calling
0 = Not responding

20. Add the column to obtain the score.
21. Place the initial of the nurse obtaining the score.
22. Mark the appropriate box and enter date and initials. For any "No" responses, explain in the nursing or focus note.
23. Any additional "Medical Condition" and the applicable protocols are noted.

RESOURCE PERSON (S): Marie Patterson, RN, CSM; Gwen Ethredge, RN