Student_________________________ Clien



Student: FORMTEXT Enter Your Name Date: FORMTEXT Enter Today's Date SEQ CHAPTER \h \r 1Client’s Initials: FORMTEXT IntialsAge: FORMTEXT AgeAdmitting Diagnosis: FORMTEXT EnterLiving Children Ages: FORMTEXT Enter AgesPP Day: FORMTEXT Enter #EDC: FORMTEXT Enter #Gravida: FORMTEXT Enter #Para: FORMTEXT Enter #Status: Hepatitis FORMCHECKBOX ???Rubella? FORMCHECKBOX HIV FORMCHECKBOX ??GBS FORMCHECKBOX Term FORMCHECKBOX Post Term FORMCHECKBOX ??Pre Term FORMCHECKBOX Gestation FORMCHECKBOX Nursing III - Postpartum Assessment (Data Collection) PhysiologicalOxygenSkin warm to touch: Yes FORMCHECKBOX No FORMCHECKBOX Skin Color: Normal For Ethnic Group FORMCHECKBOX Abnormal: Pale FORMCHECKBOX Dusky FORMCHECKBOX ??Cyanotic FORMCHECKBOX Color of nail beds: Pink FORMCHECKBOX Blue or Grey FORMCHECKBOX Dyspnea: At Rest FORMCHECKBOX ??On Exertion FORMCHECKBOX Chest Pain FORMCHECKBOX Temperature: FORMTEXT Enter Temp.Radial pulse rate: FORMTEXT Enter pulse Apical pulse rate: FORMTEXT Enter pulseBlood pressure: FORMTEXT Enter B/P Resps/min: FORMTEXT Enter RespirationFaintness/lightheadedness since delivery? Yes FORMCHECKBOX No FORMCHECKBOX Lab data: Adm Hct:? FORMTEXT Enter Hct PP Hct:? FORMTEXT Enter HctSerology: FORMTEXT Enter SerologyBlood Type: FORMDROPDOWN Rh: FORMDROPDOWN Cough FORMCHECKBOX Sputum: FORMTEXT Enter typeSmoke FORMCHECKBOX Packs Per Day: FORMTEXT Enter #Breath Sounds: FORMTEXT Enter SoundsEquipment in use: O2 FORMCHECKBOX Respiratory Rx FORMCHECKBOX Homan’s Sign: Positive FORMCHECKBOX Negative FORMCHECKBOX Fundus: Firm FORMCHECKBOX Boggy FORMCHECKBOX ???Midline: Yes FORMCHECKBOX No FORMCHECKBOX Height: FORMTEXT Enter #Lochia: Amount FORMTEXT Enter Amount Color FORMTEXT Enter ColorCondition of Breast/nipples: FORMTEXT DescribeFluids & ElectrolytesSkin turgor over sternum: Elastic FORMCHECKBOX Loose FORMCHECKBOX Tongue & Lips: Moist FORMCHECKBOX Dry FORMCHECKBOX Amount of liquids taken since 7AM today: FORMTEXT Approximate amount mLMedications: FORMTEXT List All That ApplyComments: FORMTEXT ListNausea FORMCHECKBOX Vomiting FORMCHECKBOX Presence of edema: Yes FORMCHECKBOX No FORMCHECKBOX IV: Location FORMTEXT Enter LocationSolution FORMTEXT Enter LocationLab data: FORMTEXT List DataNutritionOrdered diet: FORMTEXT Enter dietDietary supplement: FORMTEXT EnterMedications: FORMTEXT List All That ApplyLab data: FORMTEXT List DataTypical diet at home: FORMTEXT ListAppetite in hospital: FORMTEXT List Percent meal consumed: FORMTEXT Enter %Comments: FORMTEXT ListEliminationUrinaryTime of 1st PP voiding: FORMTEXT EnterSubsequent frequency & amount: FORMTEXT EnterFoley catheter: Yes FORMCHECKBOX No FORMCHECKBOX Lab data: FORMTEXT List DataMedications: FORMTEXT List All That ApplyBowelBowel sounds: FORMTEXT EnterBM since delivery: Yes FORMCHECKBOX No FORMCHECKBOX Consistency: FORMTEXT EnterLab data: FORMTEXT List DataMedications: FORMTEXT List All That ApplyMobility & ActivityMuscle strength: Handgrips equal FORMCHECKBOX Footpushes equal FORMCHECKBOX ROM: Normal FORMCHECKBOX Limited FORMCHECKBOX ??Severely limited FORMCHECKBOX Ability to ambulate: Assist FORMCHECKBOX Ambulate FORMCHECKBOX Gait: FORMTEXT EnterOOB: Chair FORMCHECKBOX BRP FORMCHECKBOX ??AdLib FORMCHECKBOX Lab data: FORMTEXT List DataMedications: FORMTEXT List All That Apply Rest, Sleep & PainReported quality of sleep: FORMTEXT EnterComplaints of pain: Yes FORMCHECKBOX No FORMCHECKBOX Location: FORMTEXT Enter loc. Intensity: FORMDROPDOWN Duration: FORMTEXT Enter dur.c/o fatigue: FORMTEXT List DataLab data: FORMTEXT List DataMedications: FORMTEXT List All That ApplySafety & SecurityVisionAble to see without glasses FORMCHECKBOX Needs glasses FORMCHECKBOX HearingResponds to normal voice tones FORMCHECKBOX ???Hearing aid FORMCHECKBOX Deaf FORMCHECKBOX SpeechClear FORMCHECKBOX Garbled FORMCHECKBOX Language Barrier FORMCHECKBOX Mental statusAlert FORMCHECKBOX Lethargic FORMCHECKBOX Unresponsive FORMCHECKBOX Environment: FORMTEXT Enter room environmentDegree of dependency/independency in caring for self: FORMTEXT EnterKnowledge of self care (breasts, episiotomy): FORMTEXT EnterSkin integrityIntact FORMCHECKBOX Reddened FORMCHECKBOX Location: FORMTEXT Enter locationBlanching erythema FORMCHECKBOX Non-Blanching erythema FORMCHECKBOX Incision/episiotomy FORMCHECKBOX Location: FORMTEXT Enter locationApproximate size in centimeters: FORMTEXT Enter #cmTreatments (dressings etc.): FORMTEXT EnterHemorrhoids FORMCHECKBOX Perineal swelling: Ice FORMCHECKBOX Sitz FORMCHECKBOX Appearance on first sight: FORMTEXT EnterFeelings about labor & delivery: FORMTEXT EnterMain focus of attention: FORMTEXT EnterAllergies: FORMTEXT EnterLove & BelongingIndicators: Cards FORMCHECKBOX Flowers FORMCHECKBOX Family pictures FORMCHECKBOX Other FORMCHECKBOX Religious affiliation: FORMTEXT Enter clients religionHelp at home: FORMTEXT EnterFamily reaction to birth (siblings, father, grandparents): FORMTEXT EnterThoughts about how baby is progressing: FORMTEXT EnterMother’s knowledge of baby care (safety, feeding, bathing): FORMTEXT EnterConcerns about taking baby home: FORMTEXT EnterSelf EsteemFamily role FORMTEXT Enter clients family role if anyOccupation FORMTEXT List All That ApplyInterest in appearance: Yes FORMCHECKBOX No FORMCHECKBOX Comments: FORMTEXT EnterReactions/communications with infant (body contact, security, etc.): FORMTEXT EnterInfant’s reaction to mother: FORMTEXT EnterRole fulfillment vs. conflict: FORMTEXT EnterSelf ActualizationClient report of satisfaction with life: Yes FORMCHECKBOX No FORMCHECKBOX Future plans for self: FORMTEXT EnterPregnancy planned? FORMTEXT EnterContraception plans: FORMTEXT EnterComments: FORMTEXT EnterErickson’s Stage of Development FORMTEXT The client is at the following developmental stage as evidenced by… ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download