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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