Labor and Delivery Assessment

7/27/2019 Labor and Delivery Assessment

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West Visayas State UniversityCOLLEGE OF NURSING

La Paz, Iloilo City

LABOR AND DELIVERY ASSESSMENT

I. VITAL INFORMATION

Name: Date of Interview:Age: Informant:Address: Relationship to Patient:Civil Status:Date and Time Admitted:Chief Complaint:Ward:Bed No.:

Allergies:Religious Affiliation:Physicians Initials:Impression/Diagnosis:

II. CLINICAL ASSESSMENT

II.A. obstetrical data

1. Age of Menarche:2. G_P_(T_P_A_L_)

3. Description of Previous Pregnancy:

4. LMP:5. EDC:6. Prenatal Check-Ups:

Date Remarks and Treatments Done


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7. Description of Present Pregnancy:

8. Medications Taken During Pregnancy:

Name of Drug Dosage, Frequency, and Route

9. Discomforts on Present Pregnancy:

10.Progress of labor


3/16

Time Duration Interval Intensity Time Duration Interval Intensity

11. Description of Each Stage of Labor:


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12. Type of Anesthtic Used:


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13. Type of Episiotomy and Description:

14. Type of Delivery:15. Type of Bow Ruptured:16. Description on Placental Delivery:

B. Gynecologic History

C. Family Planning

D. Past Health Problems

a. Childhood Illnesses

b. Immunizations

c. Allergies

d. Accidents and Injuries

e. Hospitalization for Serious Illness

f. Medications

E.Family History of Illness


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F. Patients Expectations

a.What he expects to occur during this hospitalization?

b. What he expects regarding nursing care?

II.A.5. Patterns of Functioning

a. Breathing PatternsRespiratory Problems:Usual Remedy:Manner of Breathing:

b. Circulation

Usual Blood Pressure:Any history of chest pain, palpitations, coldness of extremities, etc.:

c. Sleeping PatternsUsual Bedtime:Number of pillows:Bedtime Rituals:Problems regarding sleep:Usual remedy:

d. Drinking Patterns

Kinds of Fluid in 24

hours

Amount

Total =

e. Eating Patterns

Breakfast

Lunch

Dinner

Snacks

Usual Food Taken Time

f. Elimination patterns

1. Bowel MovementFrequency:Problems or Difficulties:Usual remedy:

2. Urination


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Frequency:Problems or Difficulties:Usual remedy:

g. Exercise

h. Personal Hygiene1. Bath

Type:Frequency:Time of Day:

2. Oral CareFrequency:Care of Dentures:

3. ShavingFrequency:

4. Use of Cosmetics

i. Recreation

j. Health Supervision

III. A. CLINICAL INSPECTIONDate and Time Taken:

1. Vital SignsT= PR=BP= RR=

2. Height: 3. Weight:

4. Physical Assessment

GENERAL APPEARANCE

A. CENTRAL NERVOUS SYSTEM/ SENSORY ASSESSMENT/ NEUROLOGICALASSESSMENT


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Cranial Nerve Patients response

CN1 OLFACTORY

CN2 OPTIC

CN3 OCULOMOTOR

CN4 - TROCHLEAR

CN5 TRIGEMINAL

CN6 ABDUCENS

CN 7 FACIAL

CN8 - ACOUSTIC

CN9 GLOSSOPHARYNGEAL

CN10 VAGUS

CN11 SPINALACCESSORY

CN12 -

HYPOGLOSSAL

B. CARDIOVASCULAR SYSTEM


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C. Respiratory System

D. GASTROINTESTINAL SYSTEM

E. GENITO-URINARY


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F. REPRODUCTIVE SYSTEM

G. LYMPHATIC SYSTEM

H. ENDOCRINE SYSTEM

I. HEMATOPOIETIC SYSTEM


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J. MUSCULOSKELETAL SYSTEM

K. INTEGUMENTARY SYSTEM

L. PSYCHOSOCIAL ASSESSMENT


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1. Lifestyle Information:

2. Normal Coping Patterns:

3. Understanding of Current Illness:

4. Personality Style:

5. History of Psychiatric Disorder:

6. Recent Life Changes or Stressors:


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7. Major Issues Raised by Current Illness:

II. Mental Status Examination

AppearanceNeat Clean Disheveled Poor Grooming Erect Posture

Good Eye Contact Inappropriate Make-up Others: _______________

Description:

BehaviorCalm Appropriate Restless Agitated Compulsions

Unusual Actions Others: ____________________

Description:

SpeechAppropriate Pressured Loose Association Loud Soft Mute

Others:

Description:

Mood/ Affect


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Appropriate Labile Flat Depressed WorriedAnxious

Angry Others_____________ Description:

ThoughtsAppropriate Low Self-esteem Suicidal Ideations Hallucinations

Delusions Phobias Others:

Description:

Ability to AbstractImpaired: YES NO

Description:

MemoryImpaired recent memory: YES NO

Impaired past memory: YES NONumber of objects able to remember after 5 minutes: _____

Description:

Estimated IntelligenceBelow Average Average Above Average

Concentration

Able to focus Easily Distractible

Able to subtract backwards by 7s from 100 correctly until numberDescription:

OrientationPerson Time Place _____ Situation ______


15/16

JudgmentRealistic decision making: YES NO

Description:

Insight

Good Fair Poor Description:


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IV. OTHER SOURCES OF DATA

I. Hematology

Date:

RESULT NORMAL VALUE SIGNIFICANCE

II. Clinicial Chemistry

Name of examination:

Date:

Protime: Patient: _______ Normal Control: ________________ Time: _______INR: _______

Normal Value: ________________

Impression:

Problem List:

Documents

Labor and Delivery Assessment