Nursing III - SUNY Orange
Nursing III
|Student: |Client’s initials: |Age: |
| |Gravida: | |
|Date: |Living children ages: |Para: |
| |Admitting diagnosis: | |
| |PP Day: | |
| | | |
POSTPARTUM ASSESSMENT (DATA COLLECTION)
Status: Hepatitis Rubella HIVGBSPHYSIOLOGICAL
|OXYGEN |Blood Type: Rh: |
|Skin warm to touch? |Cough Sputum: |
|Skin Color: Normal for ethnic group |Smokes packs per day: |
|Abnormal: Pale Dusky Cyanotic |Breath sounds: |
|Color of Nailbed: |Equipment in use: 02 Respiratory Rx |
|Dyspnea: at rest on exertion Chest pain |Homan’s Sign? |
|Temperature: |Fundus: |
|Radial pulse: Apical pulse: |Height: |
|Blood pressure: Resps/min: |Lochia: Amount: |
|Faintness/lightheadedness since delivery? |Color: |
|Breathing problems since delivery? |Condition of breasts/nipples: |
|Lab data: Adm Hct: PP Hct: | |
|Serology: | |
|FLUIDS AND ELECTROLYTES |Nausea or vomiting: |
|Skin turgor over sternum: |Presence of edema: |
|Tongue and lips: |IV: Location: |
|Amount of liquids taken since 7 AM today: _mL |Solution: |
|Medications: |Lab Data: |
|Comments: | |
|NUTRITION |Typical diet at home: |
|Ordered diet: |Appetite in hospital: % Meal consumed: |
|Dietary supplement: | |
|Medications: |Comments: |
|Lab data: | |
|ELIMINATION Urinary: |Bowel: |
|Time of 1st PP voiding: |Bowel sounds: |
|Subsequent frequency & amount: |BM since delivery? |
|Foley catheter? |Consistency: |
|Lab data: |Lab data: |
|Medications: |Medications: |
|MOBILITY AND ACTIVITY | |
|Muscle strength: Handgrips equal Footpushes equal |Lab data: |
|ROM: Normal Limited Severely limited | |
|Ability to ambulate: Assist Independent |Medications: |
|Gait____________________ | |
|OOB: Chair9 BRP9 Ad Lib9 | |
|REST, SLEEP AND PAIN | |
|Reported quality of sleep: |c/o Fatigue: |
|c/o Pain: | |
|Location: |Lab data: |
|Intensity: | |
|Duration: |Medications: |
SAFETY AND SECURITY
|Vision: |Skin integrity: |
|Able to see without glasses Needs glasses |Intact: |
|Hearing: |Reddened: Location: |
|Responds to normal voice tones |Blanching erythema: Non-blanching erythema |
|Hearing aid Deaf |Incision/epsiotomy: |
|Speech: |Location: |
|Clear Garbled Language Barrier |Approx size in cms: |
|Mental Status: |Appearance: |
|Alert Lethargic Unresponsive |Treatment (dressings etc.) |
|Environment: |Hemorrhoids |
| |Perineal swelling Ice Sitz |
|Degree of dependency/independency in caring for self: |Appearance on first sight: |
| |Feelings about labor & delivery: |
|Knowledge of self care (breasts, episiotomy): |Main focus of attention: |
| |Allergies: |
LOVE AND BELONGING
|Indicators: Cards Flowers Family pictures |Thoughts about how baby is progressing: |
|Other: |Mother’s knowledge of baby care (safety, feeding, bathing): |
|Religious affiliation: | |
|Help at home: |Concerns about taking baby home: |
|Family reaction to birth (siblings, father, grandparents): |Social service consult needed: |
| | |
SELF-ESTEEM
|Family role |Reactions/communication with infant (body contact, security, etc): |
|Occupation: | |
|Interest in appearance: |Infant’s reaction to mother: |
|Comments: |Role fulfillment vs conflict: |
SELF-ACTUALIZATION
|Client report of satisfaction with life: |Pregnancy planned? |
|Future plans for self: |Contraception plans: |
| |Comments: |
ERIKSON’S STAGE OF DEVELOPMENT
|What is the stage of development? |
|Describe client’s characteristics/behaviors that place her in this stage. |
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|Is stage appropriate for age? |
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n3padc.n33
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