Obstetrical Assessment

OBSTETRICAL ASSESSMENT

I. VITAL INFORMATION: NAME: (Initial’s only) AGE: SEX ADDRESS: RELIGIOUS AFFILIATION: ALLERGIES: (medication, food, pollens, or any contact agent, etc.) DATE OF DELIVERY: TIME OF DELIVERY:

EDUCATIONAL ATTAINMENT: CIVIL STATUS: DATE & TIME ADMITTED: PHYSICIAN’S INITIAL: CHIEF COMPLAINT: IMPRESSION/DIAGNOSIS: INFORMANT: (Patient herself, etc.) RELATIONSHIP TO PATIENT: (Patient’s son, husband, etc.)

II. OBSTETRICAL HISTORY G ___ P ____ T ____ P _____A _____ L ____ LMP:

EDC:

MENARCHE: CYCLE: DURATION: NO. OF PADS PER DAY:

TYPES OF DELIVERY: NSVD ___ CESAREAN SECTION ___OTHERS ___

EPISIOTOMY: YES _______ NO _______ TYPE OF INCISION: MEDIOLATERAL: RIGHT ___ LEFT ___ MEDIAN: PREVIOUS MEDICAL EXPERIENCE: YES __ NO ___ DATE: REASON FOR HOSPITALIZATION: (Cause, name of hospital, how the condition was treated, how long the person was hospitalized)

DATE OF LAST CONSULTATION WHILE PREGNANT: DID YOU RECEIVE ANY HEALTH TEACHINGS REGARDING? LABOR ______ POSTPARTUM ______ DELIVERY ______ NEWBORN CARE ______ DOES SHE DO ANY READING? YES ___ NO ___ IF YES, SPECIFY WHAT MATERIALS ARE BEING READ: ANY COMPLICATIONS DURING THIS PREGNANCY/PREVIOUS PREGNANCY: (History of bleeding, increased BP, GDM, etc.)

MEDICATIONS TAKEN DURING PREGNANCY:

FAMILY PLANNING: HAS FAMILY PLANNING BEEN PRACTICED? YES _______ NO _______ METHOD OF CONTRACEPTION USED: IF NO, SIGNIFIES WILLINGNESS TO PRACTICE FAMILY PLANNING? YES _______ NO _______ METHOD:

PREVIOUS PREGNANCY LOCATION

TYPE OF DELIVERY

COMPLICATIONS

DATE

III. CLINICAL ASSESSMENT III.A. NURSING HISTORY 1. HISTORY OF PRESENT ILLNESS A. USUAL HEALTH STATUS B. CHRONOLOGIC STORY (When started, description of problem, location, character, severity, timing, aggravating or relieving factors, associated factors, client’s perception of what the symptom means and thus the admission)

C. RELEVANT FAMILY HISTORY D. DISABILITY ASSESSMENT (Physical, Social, Mental, Emotional) 2. FAMILY HISTORY OF ILLNESS (Illness in family, mother, father, siblings – Heart Disease, high blood pressure, diabetes, blood disorders, cancer, arthritis, allergies, obesity, alcoholism, mental illness, etc.)

3. PATIENT’S EXPECTATIONS • WHAT SHE EXPECTS TO OCCUR DURING HOSPITALIZATION (patient’s or informant’s verbalization) • REGARDING NURSING CARE (patient’s or informant’s verbalization)

4. PATTERNS OF FUNCTIONING A. BREATHING PATTERN REPIRATORY PROBLEM: (difficulty of breathing, asthma, etc.) USUAL REMEDY: (positioning, medications, etc.) MANNER OF BREATHING: (regular/irregular, silent, effortless, etc.)

B. CIRCULATION USUAL BP: HISTORY OF CHEST PAIN, PALPITATION, COLDNESS OF EXTREMITIES: PRESENCE OF EDEMATOUS AREA:

C. SLEEPING PATTERN USUAL BEDTIME: (be specific, wake up time) HOURS OF SLEEP: NAP HABITS: PROBLEMS REGARDING SLEEP: USUAL REMEDY: NO. OF PILLOWS: (where, size of pillow) BEDTIME RITUALS: (bath, pray, etc.)

D. EATING PATTERNS APPETITE WHILE PREGNANT: DIET WHILE PREGNANT: WEIGHT GAIN: USUAL FOOD

TIME

BREAKFAST: (How many cups of rice, size, how many pieces) LUNCH: SNACKS: DINNER: FOOD LIKES: FOOD DISLIKES: FOOD PREFERENCES:

E. ELIMINATION PATTERN BOWEL MOVEMENT: (frequency) CONSTIPATION: (consistency of stool) USUAL REMEDY: (use of laxatives, increased water intake, etc.) BLADDER IRREGULARITIES: (urinary frequency, retention, dysuria, complaints, etc.)

F. REST AND ACTIVITIES ACTIVITY DURING DURATION OF PREGNANCY: REST PERIOD DURING PREGNANCY: EXERCISE DONE ON THE: FIRST TRIMESTER: SECOND TRIMESTER: THIRD TRIMESTER:

G. HEALTH SUPERVISION (ANY PRENATAL CONSULTATION DONE AND WITH WHOM) (Physician’s initial, where, what was done, frequency of visits) 5. CLINICAL INSPECTION A. VITAL SIGNS: DATE: T= R= P= BP= B. HEIGHT: WEIGHT:

C. GENERAL APPERANCE (Orientation, Facial features, body stature, nutrition, symmetry, posture, position, body build/contour, mobility (gait, range of motion), facial expression, mood and affect, clothing, speech, personal hygiene, any contraptions (IV cannula, IV fluid, O2 inhalation, etc.)

SKIN, HAIR, NAILS – Skin: color, temperature, moisture, texture, thickness, edema, mobility/turgor, vascularity, bruising, lesions; Hair: Color, texture, distribution, lesions, dandruff, pest inhabitants; Nails: shape and color, color, capillary refill, etc. HEAD, FACE & LYMPHATICS – Head/Face: size and shape, temporal area, any complaints of dizziness, facial features; Lymphatics: Symmetry, Range of Motion, lymphnodes, etc.

EYES, EARS, NOSE, THROAT, MOUTH – Eyes: PERRLA, conjunctivae and sclera, eyebrows, eyelids and lashes, eyeballs, lacrimal status, visual acquity; Ears – size and shape, symmetry, discharges/odor, tenderness, redness, swelling, lesions, hearing acquity; Nose: symmetry, patency, discharges, deformity, nasal mucosa, nasal septum, tenderness; Throat: uvula, tonsils, Mouth: lip color, moisture, lesions, halitosis, teeth and gums, tongue.

NECK & UPPER EXTREMITIES – Neck: symmetry, ROM, lymph nodes, trachea, thyroid gland Upper Extremities: Range of motion, symmetry of joints and muscles, muscle strength (5/5), skin turgor and mobility, capillary refill, deformities, edema, temperature, moisture, lesions, presence of contraptions CHEST, BREAST, AXILLAE: Chest: expansion, use of accessory muscles, rashes, pain, palpitations; Breast: symmetry of size and shape, nipples, discharges, color, temperature, engorgement, tenderness; Axillae: color, redness, tenderness, odor, perspiration, masses

THORAX, LUNGS, RESPIRATORY SYSTEM – Thoracic cage and configuration, symmetric expansion, Breath Sounds: Describe all auscultated lung sounds/clear/decreased/absent, Adventitious: rales/rhonchi/wheeze, Respiratory rate/rhythm/depth/quality/effort of breathing/dyspnea/SOB/cough HEART & CARDIOVASCULAR SYSTEM - Apical Pulse: rate/rhythm/quality, B/P: site/position; Pain: location/frequency/duration/intensity on a scale of 0 10/provokes/palleates/quality/ radiates, fatique/dizziness/chest pain/numbness/ tingling in extremeties

ABDOMEN & GI SYSTEM - Abdomen: contour, fundus, skin pigmentation, soft/distended/tenderness/colostomy, lesions, scars, hair distribution, Bowel Sounds: present/ absent, hyper/hypo active, Continence/diarrhea/constipation, Last Bowel Movement/consistency/color, Nausea/Vomiting GENITALIA/ GENITOURINARY SYSTEM – skin color, hair distribution, presence of lesions, symmetry, vaginal discharges, presence of episiotomy, swelling, bulging, urinary status, hemorrhoids, tenderness, masses

LOWER EXTREMITIES/ MUSCULOSKELETAL SYSTEM – Range of motion, symmetry of joints and muscles, muscle strength (5/5), skin turgor and mobility, capillary refill, deformities, edema, temperature, moisture, lesions

GENERAL APPRAISAL: BODY BUILT: (Ectomorph, Mesomorph, Endomorph) SPEECH: (articulation, pace of the conversation,etc.) LANGUAGE: (Dialects and languages used) HEARING: (hearing acquity) MENTAL STATUS: (consciousness, oorientation, attention, memory, perceptions, etc.) EMOTIONAL STATUS: (cooperation, mood and affect, facial expressions)

HANDICAPS & LIMITATIONS: 1. SOCIAL (Interaction with environment) 2. PHYSICAL (Need for Assistance with ADL's: Bathing, Toileting, Dressing, Feeding, Ambulating, Transferring , etc.)

IV. LABORATORY & DIAGNOSTIC PROCEDURES 1. CLINICAL CHEMISTRY: NAME OF EXAMINATION: DEFINITION: PURPOSE: RESULTS: DATE: COMPONENTS

RESULTS

NORMAL VALUES

SIGNIFICANCE

2. NAME OF EXAMINATION: URINALYSIS DEFINITION: PURPOSE: RESULTS: DATE: RESULT

NORMAL

SIGNIFICANCE

3. NAME OF EXAMINATION: HEMATOLOGY DEFINITION: PURPOSE: RESULTS: DATE: COMPONENTS

RESULTS

NORMAL VALUES

SIGNIFICANCE

4. RADIOLOGICAL EXAMS AND OTHER SPECIAL EXAMS: NAME OF EXAMINATION: DEFINITION: PURPOSE: RESULTS: DATE: IMPRESSION:

SIGNIFICANCE:

V. TEXTBOOK DISCUSSION: A. DIAGNOSIS:

PATHOPHYSIOLOGY: B. DEFINITION: C. S/Sx FOUND IN THE BOOK

MANIFESTED BY PATIENT

D. SCHEMATIC DIAGRAM MEDICAL MANAGEMENT: NURSING MANAGEMENT: HEALTH TEACHINGS: (DISCHARGE PLANNING)

ON-GOING APPRAISAL DATE: TIME: S0AP/IER-

PROBLEM LIST: 1. 2. 3. 4. 5. NURSING CARE PLAN (SEE ATTACHED SHEET) DRUG STUDY (SEE ATTACHED SHEET)

NURSING CARE PLAN Name of Patient: ______________ Attending Physician: _________ Age: ________ Ward/Bed Number: ______ Impression/Diagnosis: ____________________________________ Clustered Cues

Nursing Diagnosis

Rationale (Scientific Basis)

Objectives of Care/ Outcome Criteria (Subject+Verb+ Condition+ Criteria + Target Time)

Nursing Interventions

Rationale (Scientific Basis)

Evaluation

Student’s Name: ______________________________________ Clinical Instructor: _____________________________________

DRUG STUDY Name of Patient: ______________ Attending Physician: _________ Age: ________ Ward/Bed Number: ______ Impression/Diagnosis: ____________________________________ Name of Drug

Dosage, Route, Frequency, Timing

Generic:

Dosage:

Brand:

Route:

Classification Functional:

Frequency:

Chemical:

Timing:

Mechanism of Action

Indication

Adverse Reactions

Contraindications

Side Effects

Special Precautions

Student’s Name: ______________________________________ Clinical Instructor: _____________________________________

Nursing Responsibilities