Patient Worksheet - Postpartum 1-patient

Postpartum Assessment Guide — DeAnza College Respiratory (Air):  cough  rales  rhonchi

 dyspnea  wheezes

 breast engorgement  orthostatic hypot'n  petechiea  edema  vertigo

lochia:

/°; color:

GU (Elim/Hazards):

Diet:

Nurse:

Primary Language: Date & Time of Birth: appetite/intake:

Hct:

abd tone:

T

voiding pattern:

Hgb: P

A

Blood Type: L

Rhogam:  Needed  Given

 Vaginal  Cesarean

Rubella:  Imm  Non-imm

Feed:  Breast  Bottle

HBSAg:  Pos  Neg

Med Order

Last Given

 urine retention  dysuria

 foley: ____ Fr; @ _____ mL ________

IV:

MS (Activity/Normalcy):

fundal location:

 uterine cramping  abdominal striae

mobility:

 diastasus rectus  perineal muscles

@

cc/°; ↑

;Δ

;↓

; consistency:

Integument (Hazards/Normalcy):

pigmentation: (nipples, linea negra, striae, chloasma)

breasts:  soft  firm nipples:  dry  intact perineal:  swelling  bruising _____°  laceration  episiotomy

REEDA

CNS (Social Interaction/Hazards):

affect:

1500–1600:  charts; assess 1600–1700: chart vs; 1700–1800: 1800–1900: 1900–2000:

 tremors  clonus  DTR's

2000–2100: 2100–2130: final charting;

Health Deviation:  postpartum  infant security teaching

Room:

Childbirth Prep?

 bowel sounds x___  n/v  abd distention  constipation  diarrhea  flatus  hemorrhoids  last stool _______________________

 LOC_______________  pain_______________  epidural @ _________

Date:

 clots Cultural Background:

; odor:

 Homan's Sign  disphoresis  hematomas  hemorrhoids

GI (Food/Elim/Hazards):

 with assist?  bladder distention  oliguria

Client Initials:

Allergies:

color:

Cardiovascular (Water):

Student:

 pumping

Input:

Temp

Developmental / Emotional:

bonding:

breastfeeding consult?  neo. care (ch. 19)

social support:

 need  recv'd  inquisitive?

Vitals HR

Output:

RR Pain

Sex:

Apgar 1m:

5m:

Blood Type:

Wt.

Len.

Dir. Coombs:

BP