Patient assessment sheet
Patient Assessment Sheet
Antenatal
Assessment sheet
Name of student……………………. Date of assessment……………...
I. Mother demographic Data
Name……………………………………………..Age……………………………Religion…………………………
…
Level of
education………………………………Occupation…………………………………………………………. Address…………………………………………..Husband's occupation……………………………………………..
Habits……………………………………………………………………………………………………………………..
.
II. Family history of
a. Diabetes mellitus yes / no………………………b. Hypertension
yes / no………………….
c. Multiple Pregnancies yes / no………………………d. Genetic
disorder yes / no………………….
e. Psychiatric illness yes / no…………………………………………………………………………….
III.
Medical surgical history
a. Specify details………………………………………………………………………………………… …………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………….
IV. Menstrual history
a. Age of menarche…………………………………………b. Cycles: regular
/ irregular………………………….
c. Duration of menses………………………………………d. Interval of cycle……………………………………...
IIV. Obstetric history
Gravida……………… Para………………….Abortions…………………………Still birth………………………….
Neonatal death……………………………….No. of living
children…………… .Last child birth…………………….
A. Past obstetric history
|
Year
|
Ante natal |
Intranatal |
Post
natal |
Mode of delivery
|
Alive |
Still born
|
Sex |
Birth weight
|
||
|
|
duration |
Complication |
Nature of labor
|
normal
|
compli
catio |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
B. Present pregnancy
a) L.M.P. …………………………………………….……b. E.D.D. ……………………………………………….. II. General condition (specify)……………………………………………………………………………………… ………………………………………………………………………………………………………………………...
Height…………cm weight……..kg
Teeth………..………. Gums……………….
Breasts……………………………….Cardiovascular
system…………………….……….BP…………………
III. Abdominal
examination a. Inspection
*
Size of
abdomen……………………………………… .* Shape……………………………………………………..
*
Skin
changes………………………………………….. .* Fetal movement…………………………………………..
b. Palpation
* Fundal: height of funds…………….cm * Funds grip……………Head/buttocks…………………..
* Lateral: right……………………………………………….Left…………………………………………… …………...
* Pelvic: presentation……………………………………....Position………………..Engagement…………………….. c. Auscultation
* Fetal heart:
regular/irregular………………………………………………………..Rate…………………….
Summary of Findings:
* Gestational age:…………………………………………………* Presentation…………………………………..
* Position……………………………………………………………* Engagement………………………………….
IV. Minor discomfort / problems
* Vomiting………………………………………………. *
Constipation………………………………………………
* Muscle cramps………………………………………… * Varicose vein……………………………………………..
* Hemorrhoids…………………………………………….* Heart burn……………………………………………….. *
Edema…………………………………………………...*
Headache…………………………………………………
* Vaginal discharge…………………………………… * Any other
(specify)………………………………………..
V.
Investigations
1. Blood group & Rh Factor………………………………..HB…………………………….Stickling………………….
VDRL……………………………………………………. .TORCH……………………………………………………
2. Urine: protein…………………………………………… Sugar…………………………
Ketones…………………
3. U.S.S.
……………………………………………………………………………………………………………………
4. Special
investigations………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………
|
patient's
needs: |
Nursing interventions |
|
a) Actual needs: 1) ………………………... 2) ……………………….. 3) ……………………….. 4) ……………………….. 5) ………………………. b) health teaching needs: |
|
Labour
flowsheet
Date: ………….
Name of student: …………………….…..
Mother
name:……………………. Age:………………..
Obstetric history:
LMP:………………….. EDD:……………… GA: ………..
Obstetric Code:……………….. Parity: …………… Gravidity……… Last labor since: ……………… Mode of previous delivery: …….
Medical disorder:……………… Previous
Operation……………
Analysis:
Sugar:……………… Albumin………………… Acetone……… Others…. Last
meal since:……………… Type of meal:…………..
Complete Clinical Diagnosis:
…………………………………………………………………………………………
………………………………………………………………………………………………………………
|
Complains
|
yes |
No |
Time |
||
|
True
labor pain (TLPs) |
…….. |
…….. |
…………………
|
||
|
Show |
…….. |
…….. |
………………… |
||
|
Gush
of amniotic fluids |
…….. |
…….. |
………………… |
||
|
Bleeding
|
…….. |
…….. |
………………… |
||
|
Fundal level Engagement |
…….. |
…….. |
…………………
|
||
|
Membranes
|
…….. |
…….. |
………………… |
||
|
Parity
|
…….. |
…….. |
………………… |
||
|
Lie |
…….. |
…….. |
………………… |
||
|
Pres. |
…….. |
…….. |
………………… |
||
|
Station
|
…….. |
…….. |
…………………
|
||
|
Effacement
|
…….. |
…….. |
…………………
|
||
|
Duration of Contraction
|
…….. |
…….. |
…………………
|
||
|
Previous Operation |
…….. |
…….. |
………………… |
||
|
Risks/Problems
|
…….. |
…….. |
………………… |
||
|
Cardiovascular Disorder
|
…….. |
…….. |
………………… |
||
|
GIT.
Disorder |
…….. |
…….. |
………………… |
||
|
Respiratory.
|
…….. |
…….. |
………………… |
||
N.C.
Time of Delivery:…………………...
Sex:…………………….
Mode of Delivery:…………………. Dur: 2nd Stage :
…………………. 3rd Stage:………………. Vaginal birth:…………. Spontaneous ………………
Vacuum …….… Forceps …….. ………..
Cesarean birth:……… Primary …….
……….. ….. Repeat …………………….
Maternal
Complication:………………………………………………………………………………….
Fetal Complication:
……………………………………………………………………………………
Medication:……………………………………………………………………………………………….
Labor/delivery
anesthesia:……………Epidural ……. ……/Spinal analgesia ……………………
I.V Fluid :
………………………………………………………………………………………………..
…………………………………………………………………………………………………………….
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
Medication
|
Medication |
Time |
Type |
Dose |
Route |
Notes |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Nursing problems or needs
1
…………………………………………………………………………………………………
2
…………………………………………………………………………………………………
3
…………………………………………………………………………………………………
4
…………………………………………………………………………………………………
5
…………………………………………………………………………………………………
Second and third stage
-Time of delivery:………………… Mode of delivery…………………….
-Duration of:
2nd stage………………
3rd stage……..…...
-Maternal complication
……………………………………………………………………………………
-Fetal
complication ………………………………………………………………………………
-Sex of
baby………………………….
Nursing Care
|
Nursing problem or need
|
Nursing Intervention
|
Evaluation
|
|
|
|
|
APGAR SCORE
Mother name:
Mode of delivery:
Sex of baby:
Date of delivery:
|
sign |
0 |
1 |
2 |
|
over 100 good crying active motion cry & cough normal |
slow (below 100) slow (irregular) some flextremities grimace
extremities blue |
absent absent flaccid absent blue, pale |
heart rate respiratory rate muscle tone reflexes color |
First minute ………/ 10
Five minute ……… /10
Wt …… kg
Ht ……. Cm Chest circumference ……. Cm head circumference …….
Cm
Baby record
- Mother name:
- Baby sex:
- Baby weight:
- Apgar score
- Environment
- Mode of delivery
- Date and time of delivery
|
Date/ time |
Vial signs |
New born assessment |
feeding |
Out put |
Nursing care |
|
T…… P…… R…… B.P…. |
C.V.S G.I.T G.U.S Neuro Skin |
Breast …….. Artificial ……….. |
Voiding ………. Defecation ………. |
|
|
Post partum assessment sheet
Name
of student……………………. Date of assessment……………...
I. Client Demographic Data
Name……………………………………………..Age………………Religion………………
Education level……………………Occupation……………………………………………………
Address…………………..Husband's occupation……………………………………………..
Habits…………………………………………………………………………
Date & time of delivery………….type of delivery………..
word num,……...
II. history of disease:-
a. Diabetes mellitus yes / no………b. Hypertension
yes /no………………….
c. hepatitis yes / no……………… d. Genetic disorder yes/no…………………
Vital
signs:-
Temperature………………. Pulse………………..
B.p…………….respiratory…………………….
III.
Physical Examination
1.Breast normal Yes/No engorgement present……….no
Any other
yes/ no If other
specify………………………………………………………………………………………………….
2. nipples normal yes/ no
Sore / cracked present……… absent
Inverted / flat yes………. No
Lactation initiated yes …………no
3. Uterus:-
Height of funds………………. Cm Contracted yes…………………..no……….
Abnormal finding……………………… Hyper involution yes………………….no………..
Sub involution yes………………….no………..
Bulky uterus yes………………….no………..
Tender yes………………….no…………
4. Perineum & Anus Intact
yes………………….no………..
Episiotomy yes………………….no……….. Laceration
yes………………….no………..
Edges well- approximated yes………………….no………..
Drainage yes………………….no………..
Pain yes………………….no………..
Hemorrhoid yes………………….no………..
D) Lochia :
Type……………………………….
Amount…………………………… Color………………………………
Odor…………………………….
Consistency……………………..
e) Extremities:
Tender yes…………. …….No…………….
Edematous yes………………….no………..
Inflamed yes…………………..no………..
Varicose vein present ………………no……..
f) Elemination:
Bowels……..normal…………….. yes………………….no………..
Micturation normal yes………………….no………..
If any specify…………………………………………………………………………………
g) Maternal – infant
interaction:
Touched yes………………….no………..
Hold yes………………….no………..
Communicate yes………………….no………..
Eye contact yes………………….no………..
Breast feeding yes………………….no………..
h) Medication:-
…………………………………………………………………………………………………….
……………………………………………………………………………………………………..
…………………………………………………………………………………………………….
……………………………………………………………………………………………………..
SUMMARY OF FINGING :-
………………………………………………………………………………………………………
……………………………………………………………………………………………………….
………………………………………………………………………………………………………..
……………………………………………………………………………………………………….
Baby record
- Mother name:
- Baby sex:
- Baby weight:
- Apgar score
- Environment
- Mode of delivery
- Date and time of delivery
|
Date/ time |
Vial signs |
New born assessment |
feeding |
Out put |
Nursing care |
|
T…… P…… R…… B.P…. |
C.V.S G.I.T G.U.S Neuro Skin |
Breast …….. Artificial ……….. |
Voiding ………. Defecation ………. |
|
|
Nursing Care
|
Nursing problem or need
|
Nursing Intervention
|
Evaluation
|
|
|
|
|
Family Planning Record
Nursing Care
|
Nursing problem or need
|
Nursing Intervention
|
Evaluation
|
|
|
|
|
Gynecological sheet
- Student name: -
Date:
-patient
name: -
Marital duration:
- Occupation: -Level
of education: Previous marriage: yes ( ) No ( ) -Special habits:
Smoking ( )
Exercise ( )
Alcohol intake ( )
Obstetric
history:-
Para
Gravida
abortion
Age of youngest child
Menstrual
history:
-Age of menarche
-Duration
-Rhythm
-Average interval between periods
Menstrual
abnormalities:
• Menorrhegia
• Oligomeria
• Intermenstrual bleeding
• Hypomenorrhea
• Dysmenorrheal Contraception:
|
no |
pills |
IUD |
tubal ligation |
infection |
local |
|
-duration -stopped -since |
|
|
|
|
|
Causes
of examination:
- Routine
- Symptomatic
- Infertility
- Bleeding
- Itching
- discharge
Medical
history:
- drugs
- cytology ( ……exam , …………. Smear)
(Date………………, place……………., and number ………… )
- colostomy, hysterectomy
- biopsy ( endometrial, cervical)
Condition
of cervix:
- healthy
- others
…………………………………………………………….
- Infection
- Non specific
- Candida
- Herps
- Chlamydia
Hormonal study:
................................
……………………
Nursing Care
|
Nursing problem or need
|
Nursing Intervention
|
Evaluation
|
|
|
|
|
تعليقات
إرسال تعليق