Labor and Delivery Assessment
Content
West Visayas State University COLLEGE OF NURSING La Paz, Iloilo City LABOR AND DELIVERY ASSESSMENT I. VITAL INFORMATION Name: Age: Address: Civil Status: Date and Time Admitted: Chief Complaint: Ward: Bed No.: Allergies: Religious Affiliation: Physician’s 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 Date of Interview: Informant: Relationship to Patient:
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
Time
Duration
Interval
Intensity
Time
Duration
Interval
Intensity
11. Description of Each Stage of Labor:
12. Type of Anesthtic Used:
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
F. Patient’s 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 Patterns Respiratory Problems: Usual Remedy: Manner of Breathing: b. Circulation Usual Blood Pressure: Any history of chest pain, palpitations, coldness of extremities, etc.: c. Sleeping Patterns Usual 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
=
Usual Food Taken Breakfast Lunch Dinner Snacks
Time
f. Elimination patterns 1. Bowel Movement Frequency: Problems or Difficulties: Usual remedy:
2. Urination
Frequency: Problems or Difficulties: Usual remedy: g. Exercise h. Personal Hygiene 1. Bath Type: Frequency: Time of Day: 2. Oral Care Frequency: Care of Dentures: 3. Shaving Frequency: 4. Use of Cosmetics i. Recreation
j. Health Supervision
III. A. CLINICAL INSPECTION Date and Time Taken: 1. Vital Signs T= BP= 2. Height: 4. Physical Assessment GENERAL APPEARANCE PR= RR= 3. Weight:
A. CENTRAL NERVOUS SYSTEM/ SENSORY ASSESSMENT/ NEUROLOGICAL ASSESSMENT
Cranial Nerve CN1 – OLFACTORY
Patient’s response
CN2 – OPTIC
CN3 – OCULOMOTOR
CN4 - TROCHLEAR
CN5 – TRIGEMINAL
CN6 – ABDUCENS
CN 7 – FACIAL
CN8 - ACOUSTIC CN9 – GLOSSOPHARYNGE AL CN10 – VAGUS
CN11 – SPINAL ACCESSORY CN12 HYPOGLOSSAL
B. CARDIOVASCULAR SYSTEM
C. Respiratory System
D. GASTROINTESTINAL SYSTEM
E. GENITO-URINARY
F. REPRODUCTIVE SYSTEM
G. LYMPHATIC SYSTEM
H. ENDOCRINE SYSTEM
I. HEMATOPOIETIC SYSTEM
J. MUSCULOSKELETAL SYSTEM
K. INTEGUMENTARY SYSTEM
L. PSYCHOSOCIAL ASSESSMENT
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:
7. Major Issues Raised by Current Illness:
II. Mental Status Examination Appearance Neat Clean Disheveled Poor Grooming Erect Posture
Good Eye Contact Description:
Inappropriate Make-up
Others: _______________
Behavior Calm
Appropriate
Restless
Agitated
Compulsions
Unusual Actions Description:
Others: ____________________
Speech Appropriate Others: Description:
Pressured
Loose Association
Loud
Soft
Mute
Mood/ Affect
Appropriate Anxious Angry Description:
Labile
Flat
Depressed
Worried
Others_____________
Thoughts Appropriate Delusions Description:
Low Self-esteem Phobias
Suicidal Ideations Others:
Hallucinations
Ability to Abstract Impaired: Description:
YES
NO
Memory Impaired recent memory: YES NO Impaired past memory: YES NO Number of objects able to remember after 5 minutes: _____ Description:
Estimated Intelligence Below Average
Average
Above Average
Concentration Able to focus Easily Distractible
Able to subtract backwards by 7’s from 100 correctly until number Description:
Orientation Person
Time
Place _____
Situation ______
Judgment Realistic decision making: Description:
YES
NO
Insight Good Description: Fair Poor
IV. OTHER SOURCES OF DATA I. Hematology Date: RESULT NORMAL VALUE SIGNIFICANCE
II. Clinicial Chemistry Name of examination: Date: Protime: Patient: _______ Time: _______ INR: _______ Normal Value: ________________ Impression: Normal Control: ________________
Problem List:
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
Time
Duration
Interval
Intensity
Time
Duration
Interval
Intensity
11. Description of Each Stage of Labor:
12. Type of Anesthtic Used:
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
F. Patient’s 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 Patterns Respiratory Problems: Usual Remedy: Manner of Breathing: b. Circulation Usual Blood Pressure: Any history of chest pain, palpitations, coldness of extremities, etc.: c. Sleeping Patterns Usual 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
=
Usual Food Taken Breakfast Lunch Dinner Snacks
Time
f. Elimination patterns 1. Bowel Movement Frequency: Problems or Difficulties: Usual remedy:
2. Urination
Frequency: Problems or Difficulties: Usual remedy: g. Exercise h. Personal Hygiene 1. Bath Type: Frequency: Time of Day: 2. Oral Care Frequency: Care of Dentures: 3. Shaving Frequency: 4. Use of Cosmetics i. Recreation
j. Health Supervision
III. A. CLINICAL INSPECTION Date and Time Taken: 1. Vital Signs T= BP= 2. Height: 4. Physical Assessment GENERAL APPEARANCE PR= RR= 3. Weight:
A. CENTRAL NERVOUS SYSTEM/ SENSORY ASSESSMENT/ NEUROLOGICAL ASSESSMENT
Cranial Nerve CN1 – OLFACTORY
Patient’s response
CN2 – OPTIC
CN3 – OCULOMOTOR
CN4 - TROCHLEAR
CN5 – TRIGEMINAL
CN6 – ABDUCENS
CN 7 – FACIAL
CN8 - ACOUSTIC CN9 – GLOSSOPHARYNGE AL CN10 – VAGUS
CN11 – SPINAL ACCESSORY CN12 HYPOGLOSSAL
B. CARDIOVASCULAR SYSTEM
C. Respiratory System
D. GASTROINTESTINAL SYSTEM
E. GENITO-URINARY
F. REPRODUCTIVE SYSTEM
G. LYMPHATIC SYSTEM
H. ENDOCRINE SYSTEM
I. HEMATOPOIETIC SYSTEM
J. MUSCULOSKELETAL SYSTEM
K. INTEGUMENTARY SYSTEM
L. PSYCHOSOCIAL ASSESSMENT
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:
7. Major Issues Raised by Current Illness:
II. Mental Status Examination Appearance Neat Clean Disheveled Poor Grooming Erect Posture
Good Eye Contact Description:
Inappropriate Make-up
Others: _______________
Behavior Calm
Appropriate
Restless
Agitated
Compulsions
Unusual Actions Description:
Others: ____________________
Speech Appropriate Others: Description:
Pressured
Loose Association
Loud
Soft
Mute
Mood/ Affect
Appropriate Anxious Angry Description:
Labile
Flat
Depressed
Worried
Others_____________
Thoughts Appropriate Delusions Description:
Low Self-esteem Phobias
Suicidal Ideations Others:
Hallucinations
Ability to Abstract Impaired: Description:
YES
NO
Memory Impaired recent memory: YES NO Impaired past memory: YES NO Number of objects able to remember after 5 minutes: _____ Description:
Estimated Intelligence Below Average
Average
Above Average
Concentration Able to focus Easily Distractible
Able to subtract backwards by 7’s from 100 correctly until number Description:
Orientation Person
Time
Place _____
Situation ______
Judgment Realistic decision making: Description:
YES
NO
Insight Good Description: Fair Poor
IV. OTHER SOURCES OF DATA I. Hematology Date: RESULT NORMAL VALUE SIGNIFICANCE
II. Clinicial Chemistry Name of examination: Date: Protime: Patient: _______ Time: _______ INR: _______ Normal Value: ________________ Impression: Normal Control: ________________
Problem List:
