OBSTETRIC HISTORY & PHYSICAL EXAM FORM

Student _Sydonie Stock___________________ Date __6/3/13__________________

Please review GUIDELINES FOR NURSING HISTORIES before beginning.

BIOGRAPHICAL DATA
A. Pt. init. _M. C.__ Age _33___ DOB _9/5/1979_ Religion Christian_ Race
Caucasian
B. Marital status (check one) Single Married X Separated Divorced Widowed
C. Nearest relative/support person (relationship only) _Husband ____________
BRIEF SOCIAL HISTORY
A. Where employed _FSU Admissions___ Occupation _Part-time Clerical_________
B. Highest education __Bachelors degree in Interior Design ____________________
CURRENT PREGNANCY
A. Expected date of delivery June 19, 2013 Gravida __1____ Para __ 0__ Ab __0____
B. Type of childbirth preparation birthing class, plans to go to MCMC for delivery ___ Date
last seen by Dr. May 30, 2013_
C. Allergies/sensitivities _None_____________________________________________
D. Special problems this pregnancy and treatment __None________________________
_____________________________________________________________________
E. Laboratory assessment (if known):
Blood type ___A_____ Rh ___+_____ Fathers blood type Unknown Rh Unknown
Anemia? No_____
F. Nursing assessment:
Pre-pregnant Wt _160___ Present Wt _200___ Ht _54__

G. Minor discomforts (check all that apply):
Mood swings
X
Nocturia (started last
week)
Pain (where)
Dyspareunia
X
Backache (mild) X Vaginal discharge

X
Fatigue (in 1
st

trimester and
again recently)
Leg cramps
X
Numbness or swelling of feet, fingers, ankles
(Feet started swelling last week)
Varicosities Constipation
X
Itching of skin or vulva
Insomnia
X
Frequent urination
X
Other: Yeast infection
X Heart Burn
(lots)
Anxiety
Have you had or been exposed to a major infection? (When)
(What)



IV. PAST HEALTH AND MENSTRUAL HISTORY
Write in this space pertinent information related to residual or chronic illness.
_None___________________________________________________________
____________________________________________________________________

Last X-rays _May 23, 2013_ Type _Ultrasound___________________________
What medications and vitamins are you taking and why? _Prenatal vitamins to help the
baby grow___________________________________________________________________

V. PAST CONTRACEPTIVE HISTORY


X
Oral IUD Gels & Foams Rhythm
Norplant
X
Condoms DEPO Provera
A. Previous Pregnancy History:
DOB Sex Birth weight Prem/FT/Stillbirth Living
N/A N/A N/A N/A N/A



B. Previous children with problems after birth? Explain _N/A, first pregnancy_________
____________________________________________________________________
____________________________________________________________________

C. Problems with previous pregnancies (excessive vomiting, multiple births, excessive wt.
gain, closely spaced pregnancies, etc.) Explain _N/A, first pregnancy .
______________________________________

D. Problems with previous labors and/or deliveries (extended labor periods, excessive
bleeding, abnormal fetal position, etc.) Explain _N/A, first pregnancy ___
_____________________________________________________________________

E. Postpartum problems (sub-involution, infection, excess bleeding, bladder, etc.) Explain
__N/A, first pregnancy _____________________________________
_____________________________________________________________________

VI. DIET ASSESSMENT
No. of meals per day _3___ No. of snacks per day __2__ Fluid intake per day 5-6 8oz glasses
Pica __ice cream______ Peculiarities (social-cultural, religious, economic, etc.)
_none____________________________________________________________________
_____________________________________________________________________
Typical Daily Food Intake in 24-hr period (sample) does not know amount. Was careful
about portions during trimesters 1 and 2, but has not paid attention during 3
rd
trimester.

Breakfast Lunch Dinner Snacks
Food Amount Food Amount Food Amount Food Amount
Cereal,
toast, or
oatmeal

Tortilla
with
Peanut
Butter
Grilled
chicken
Blueberries,
strawberries,
carrots with
peanut
butter, or ice
cream

Cottage
Cheese
Vegetables
Fruit Pasta/
noodles

NUTRITION LIMITATIONS

What do you consider to be your healthy weight? __156_____
Do you eat at least 3 meals a day? Yes, 3 full meals, usually 2
snacks. The time between breakfast and lunch is hardest to go
without a snack.
Are you on a special diet? No, just eating healthy
Do you take folic acid? Yes, in the prenatal vitamin
Do you have current or past problem with an eating disorder? No
Do you have any dental problems? No
When was your last check up? _Last OB check up was May 30th
Do you have any vision problems? Wears glasses for driving long distances, nearsighted
Can you hear without problems? Yes
Do you have any speech problems? No
Do you have any learning problems? No
Do you have any physical limitations? No

FEARS/ANXIETIES ABOUT PREGNANCY AND PARENTING

Personal Health - none
Personal Safety - none
Fetal Condition not overwhelming, just in the back of her mind, hopes everything is normal
Early Pregnancy Loss - past that stage
Pregnancy Complications doesnt expect any complications, hasnt had any so far
Hospital doesnt enjoy hospitals, but has no fear or anxiety about them
Surgery - none
Anesthesia a little anxiety; does not like the feeling of numbness, doesnt want an epidural
Perinatal Loss - none
Labor/Delivery a little anxiety, wants everything to go smoothly, worries that it will take a
long time
Infant Illness havent thought too much about it; just wants to get the baby delivered first
Infant Attachment - none
Parenting Skills yes, this is M. C. and her husbands first kid
A. Perception and knowledge of pregnancy and delivery (in clients own words)
Before I got pregnant, I heard all the horror stories about how awful it was, the heart
burn, the swelling, the discomfort, but my pregnancy has really been enjoyable, I only
had a couple weeks of mild nausea, and once that passed, Ive felt great. Labor, I
expect will be painful and difficult. _______________________________

B. Attitude toward pregnancy _very positive attitude, It is enjoyable______
____________________________________________________________

C. Questions asked by mother-to-be _none. Prenatal class was very thorough, all of our
questions were answered there.________________________________
____________________________________________________________
____________________________________________________________

WORK/SCHOOL ACTIVITIES EXPOSURE

Have you experienced the loss of a co-worker and/or friend at work or school? Lost two
coworkers to cancer at previous job, was not close to them, but was still sad for the loss.
Have you been threatened recently at work or school? No
Have you been involved in an argument or fight at work or school? No
Have you recently changed jobs? Started at FSU in November, was not working for 9 months
previously, was at last job for 9 years
Have you recently changed school? No, not attending school
Quit school? No
Do you use heavy equipment? No
Do you work long hours? No, part-time hours
Do you do heavy housework? No, normal, light housework
Do you often stand for 30 minutes or more at a time? No
Do you often lift more than 20 pounds? No
Do you have problems climbing stairs? No
Do you play sports? No
Do you ride in a car more than 1 hour a day? No
Do you have a disability that limits activity? No
Are you exposed to:
Paint thinners or oven cleaners? No
Strong cleaners? No, normal household cleaners
Cat litter? No
Mercury or lead? No
Ceramics, stained glass, or jewelry making products? No
Have you eaten raw or uncooked meat? No
Do you wear your seat belt? Yes
How many sexual partners have you had in the past year? _1, husband____
Are you now using/taking or have you ever taken/used hard drugs? _No ________
Which one(s)? __________________________________________________
Amount ____________________ _____
Frequency _______________ ___________
How many cigarettes do you smoke daily? _None Any marihuana? _None ________
Do others smoke around you? No
How much alcoholic beverage do you drink per day/week? _None ______________

HOUSEHOLD SOCIAL SUPPORT RESOURCES

How many children do you care for in your home? None
Ages: ________________
Do you care for a family member with a disability? No
Do you have a serious illness? No
Recent or planned move? December 2011, moved to Big Rapids
Do you feel sleepy or tired a lot? Lately, feels like she needs a nap once a day
Do you feel safe where you live? Yes
Do you or anyone in your house ever go to bed hungry? No
Do you have any problems that keep you from health care appointments? No
Do you have family who will help you? Husband and parents live in the area
Do you have friends you can count on when you need help? Has not made any close friends,
but has family to help her
Are you not getting along with or arguing with your:
Partner - No
Parent No
Friends - No
Child - N/A
Other ________________
Do you have a car or access to transportation? Yes.
Do you have access to a telephone? Yes.
Do you receive:
Food Stamps - No
TANF/Welfare - No
Help with Child Care - No
Help with housing - No
WIC - No
INFORMATION ON BABYS FATHER

Do you know for certain whom the father of the baby is? Yes, husband.
If yes, what is the age of the babys father? _39_ Is the babys father here with you today? No
How long have you known the babys father? _2 years_ Is the babys father happy about your
pregnancy? Yes.
Do you currently live with the babys father? Yes
Are you married to the babys father? Yes
Is the babys father currently married to someone else? No
Does the babys father have children not in the home? No
If yes, how many children does he have? ________
What is his/her age? ________
How long have you known your partner? _(see above)_______ Is he/she happy about your
pregnancy?
Does your partner have children not in the home?
If yes, how many does he/she have? ________

LIFE STRESSORS MENTAL HEALTH VIOLENCE/ABUSE

Was your pregnancy planned? Not planned, but had been talking about starting a family
Do you want to parent this child? Yes
Do you have enough money to pay for food, housing, & bills? Yes
Have you recently experienced an extremely stressful event (house fire, tornado, death)? No
Do you feel overwhelmed, sad, hopeless, or lost pleasure in the things usually enjoyed? No
Are you having any problems sleeping? No
Have you recently thought about suicide? No
Have you ever attempted suicide? No.
When? ____________
Have you ever been diagnosed with a mental health condition? No
Have you been hospitalized for a mental health condition? No
Did you attend or currently attend mental health counseling? No
Are you ever afraid of your partner? No
In the last year, has anyone at home hit, kicked, punched, or otherwise hurt you? In
the last year, has anyone at home often put you down, humiliated you or tried to
control what you can do? No
In the last year, has anyone at home threatened to hurt you? No
Have you in the past or recently been a victim of:
Rape/Sexual Assault? No
Past Recent
Mental Abuse? No
Past Recent
Crime Victim? No
Past Recent
Have you ever been investigated for hurting or neglecting a child? No


BABYS FATHER OR CURRENT PARTNER IN THE HOME

Does the babys father or your current partner use:
Tobacco? No
Alcohol? No
Marijuana? No
Cocaine? No
IV Drugs? No
Meth? No
Is he bi-sexual? No
Does he have multiple partners? No
Is the babys father or your current partner employed? Yes, teaches at Morley/Stanwood

VII. PHYSICAL ASSESSMENT
General Appearance (DO NOT put good or WNL):
Appears healthy, did not show any signs of difficulty when she was walking with me to our
meeting room, seems happy and excited about the pregnancy and upcoming delivery.
Educational Needs/Interventions

On the basis of your assessment, list at least TWO nursing diagnoses for your patient, interventions (min 3/nursing diagnosis),
assessments for each nursing diagnosis, and the rationale for your actions. Please have supporting evidence from the literature for your
plan. Be sure your assessment and interventions correspond to your Nursing Diagnosis.



Nursing Diagnosis Necessary Assessments/Interventions Rationale
1. Anxiety r/t unknown
future, threat to self,
secondary to pain of
labor (Ladwig & Ackley,
2011)











2. Readiness for
enhanced Self-Health
management: seeks
information for
Anxiety: 1. Assess the clients level of anxiety and physical
reactions to anxiety, 2. If the situational response is
rational, use empathy to encourage the client to interpret
the anxiety symptoms as normal, 3. Provide
backrubs/massage for the client to decrease anxiety
(Ladwig & Ackley, 2011)










Self-Health management: 1. Acknowledge the expertise
that the client and family bring to self-management, 2.
Support all efforts to self-manage therapeutic regimens, 3.
Provide knowledge as needed related to the
1. Massage during labor and childbirth can reduce the
anxiety and fear the mother is experiencing but may
not feel safe voicing and can provide exceptional pain
relief (Adams, 2012). Although not part of the nursing
diagnoses chosen, a study has shown that 20 minutes of
foot massages each day near the end of the pregnancy
reduces swelling and edema (Adams, 2012), which M.
C. has noticed developing. Since M. C. is worried about
the pain of childbirth, she might benefit from perineal
massage. This is a technique used to slowly stretch the
the tissues surrounding the posterior half of the
vaginal opening (Adams, 2012). Women who have
performed this massage technique have less perineal
trauma at birth, require fewer sutures, and in some
cases, have avoided the need for an episiotomy
(Adams, 2012).
2. A study examining methods to limit gestational weight
gain within the healthy limits discussed the need for
self-efficacy, or one's own confidence in his/her ability
to make changes (Hill et al, 2013). This also applies to a
prenatal self-care
(Ladwig & Ackley, 2011)





3. Impaired Urinary
elimination r/t
frequency caused by
increased pelvic
pressure and hormonal
stimulation (Ladwig &
Ackley, 2011)
pathophysiology of pregnancy, prescribed activities,
prescribed medications, and nutrition (Ladwig & Ackley,
2011)




Urinary elimination: 1. Teach client to avoid dehydration,
even though she is getting up every few minutes to use the
restroom, 2. Teach client that the urinary frequency is part
of the natural progression of pregnancy, 3. Encourage client
to not bring a drink to bed and use the restroom before
going to bed (Ladwig & Ackley, 2011)
persons general health, not just weight control. By
supporting M. C.s health decisions, she gains
confidence in her choices and will be more likely to
make positive health decisions throughout the
pregnancy and beyond. Hill et al (2013) found that
constructive coping strategies positively related to self-
efficacy.
3. A study conducted in Finland from 2003 to 2004
defined nocturia as voiding 2 or more times during the
night and urgency was defined as the sudden
compelling desire to urinate often or always (Tikkinen,
2008). Ricci (2009) suggested to limit fluid intake 2 to 3
hours before bedtime (p. 308). Kegel exercises could
help strengthen perineal muscle control, increasing
urinary control (Ricci, 2009, p. 308).


References:

Adams, J. D. (2012). Massage and other CAM in pregnancy. International Journal Of Childbirth
Education, 27(3), 37-42.
Hill, B., Skouteris, H., McCabe, M., Milgrom, J., Kent, B., Herring, S. J., & ... Gale, J. (2013). A
conceptual model of psychosocial risk and protective factors for excessive gestational
weight gain. Midwifery, 29(2), 110-114. doi:10.1016/j.midw.2011.12.001
Ladwig, G. & Ackley, B. (2011). Mosbys guide to nursing diagnosis (3rd ed). Maryland
Heights, MO: Mosby/Elsevier.
Ricci, S. (2009). Essentials of maternity, newborn, and womens health nursing (2
nd
ed).
Philadelphia, PA: Lippincott, Williams, & Wilkins.
Tikkinen, K., Auvinen, A., Tiitinen, A., Valpas, A., Johnson, T., & Tammela, T. (2008).
Reproductive factors associated with nocturia and urinary urgency in women: a
population-based study in Finland. American Journal Of Obstetrics & Gynecology,
199(2), 153.e1-12.