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: 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 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. 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 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

Patients 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 7s 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: