Semi-Finals: Postpartum Woman

DATA BASE AND HISTORY

Name of Patient: _______________________ Sex: _____ Age: _____ Religion: ______________
Civil Status: _______________ Income: __________________ Nationality: _________________
Date Admission: ________________ Time: ___________ Informant: ______________________
Temperature: ______________ Pulse Rate: ___________ Resp. Rate: ___________ BP: _______
Height: ____________ Weight: _____________

Chief Complaint and History of Present Illness

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Type of Previous Illness Type of Previous Illness

Date Date
Pregnancy/Delivery Pregnancy/Delivery

Has received blood in the past: ___ Yes ___ No; If yes, list dates _____ Reaction ___ Yes ___ No
Medication Dose / Time of Name of Dose / Time of Last
Name Frequency Last Dose Medication Frequency Dose

Admitting diagnosis: ____________________________________________________________

Attending Physician: ____________________________________________________________
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 Score: __________
Grade: __________
NURSING SYSTEM REVIEW CHART
Name: __________________________________________________ Date: _______________
Vital Signs:
Pulse: __________BP: __________Temp: __________Height: __________Weight: __________
INSTRUCTIONS: Place an (X) in the area of abnormality. Write comment on the space provided.
Indicate the location of the problem in the figure using (X).
EENT:
[ ] impaired vision [ ] blind ________________
[ ] pain reddened [ ] drainage ________________
[ ] burning [ ] edema [ ] lesion teeth ________________
[ ] assess eyes, ears, and nose ________________
[ ] throat for abnormality [ ] no problem ________________
RESPIRATION ________________
[ ] asymmetric [ ] tachypnea [ ] barrel chest ________________
[ ] apnea [ ] rales [ ] cough ________________
[ ] bradypnea [ ] shallow [ ] rhonchi ________________
[ ] sputum [ ] diminished [ ] dyspnea ________________
[ ] orthopnea [ ] labored [ ] wheezing ________________
[ ] pain [ ] cyanotic ________________
[ ] assess resp. rate, rhythm, depth, pattern ________________
[ ] breathe sounds, comfort [ ] no problem ________________
GASTRO INTESTINAL TRACT ________________
[ ] obese [ ] distention [ ] mass ________________
[ ] dysphagia [ ] rigidly [ ] pain ________________
[ ] assess abdomen, bowel habits, swallowing ________________
[ ] bowel sounds, comfort [ ] no problem ________________
GENITO-URINARY and GYNE ________________
[ ] pain [ ] urine color [ ] vaginal bleeding ________________
[ ] hermaturia [ ] discharge [ ] noctoria ________________
[ ] assess urine freq., control, color, odor, comfort ________________
[ ] gyn-bleeding [ ] discharge [ ] no problem ________________
NEURO ________________
[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures ________________
[ ] lethartic [ ] comatose [ ] vertigo [ ] tremors ________________
[ ] confused [ ] vision [ ] grip ________________
[ ] assess motor function, sensation, LOC, strength ________________
[ ] grip, gait, coordination, speech [ ] no problem ________________
MUSCULOSKELETAL and SKIN ________________
[ ] appliance [ ] stiffness [ ] itching [ ] petechiae ________________
[ ] hot [ ] drainage [ ] prosthesis [ ] swelling ________________
[ ] lesion [ ] poor turgor [ ] cool [ ] deformity ________________
[ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic moist ________________
[ ] assess mobility, motion, gait, alignment, joint function ________________
[ ] skin color, texture, turgor, integrity [ ] no problem ________________

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 NURSING ASSESSMENT 2
SUBJECTIVE OBJECTIVE
COMMUNICATION:
 Healing loss Comments: __________  Glasses  Languages
 Visual changes ____________________  Contact lens  Hearing aide
 Denied ____________________ R L
____________________ Pupil Size: __________  Speech difficulties
____________________ Reaction: ___________
OXYGENATION:
 Dyspnea Comments: ___________ Resp.  Regular  Irregular
 Smoking history _____________________ Describe: ______________________________________
 Cough _____________________ ______________________________________________
 Sputum _____________________
 Denied _____________________ R: ____________________________________________
_____________________ L: ____________________________________________

CIRCULATION:
 Chest pain Comments: ___________ Heart Rhythm  Regular  Irregular
 Leg pain _____________________ Ankle Edema: ___________________________________
 Numbness of _____________________ Carotid Radial Dorsalis Pedis Femoral
extremities _____________________ R: _____________________________________________
 Denied _____________________ L: _____________________________________________
_____________________ Comments: ______________________________________
_____________________ ________________________________________________
_____________________ *If applicable ____________________________________

NUTRITION:
Diet Comments: ____________  Dentures  None
 N  V _____________________
 Recent change in _____________________ Full Partial With Patient
weight an appetite _____________________ Upper   
 Difficulty in _____________________
swallowing _____________________ Lower   
 Denied _____________________
ELIMINATION: Comments: _____________ Bowel Sounds: __________
Usual bowel pattern  Urinary frequency _______________________ _______________________
________________________
________________________ _______________________ Abdominal Distention
 Constipation  Urgency _______________________ Present  Yes  No
remedies  Dysuria _______________________ Urine* (color,
________________________  Hematuria _______________________ consistency, odor)
Date of last BM  Incontinence _______________________
_____________________
________________________  Polyuria _______________________
_______________________
 Diarrhea character  Foley in place
_______________________
*if foley bag catheter is in
_______________________
 Denied place
MGT. OF HEALTH & ILLNESS: Briefly describe the patient’s ability to follow treatments
 Alcohol  Denied (diet, meds, etc.) for chronic health problems (if present).
(amount, frequency)
__________________________________________________ ________________________________________________
__________________________________________________ ________________________________________________
 SBE Last Pap Smear: _______________________ ________________________________________________
LMP:

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 SUBJECTIVE OBJECTIVE
SKIN INTEGRITY:  dry  cold  pale
 Dry Comments:  flushed  warm
 Itching ______________  moist  cyanotic
 Other ______________ *rashed, ulcers, decubitus (describe size, location,
 Denied ______________ drainage) ____________________________________
______________ ____________________________________________
______________ ____________________________________________
ACTIVITY / SAFETY:  LOC and orientation: _____________________
 Convulsion Comments: - ________________________________________
 Dizziness ______________ Gait:  walker  care  other
 Limited motion of joints ______________  steady  unsteady
Limitation in ability to ______________ Sensory and motor losses in face or extremities
 Ambulate ______________ ____________________________________________
 Bathe self ______________ ____________________________________________
 Other ______________ ____________________________________________
 Denied ______________ ROM limitations: _____________________________
______________ ____________________________________________
______________ ____________________________________________
COMFORT / SLEEP / AWAKE  facial grimaces
 Pain Comments:  guarding
(location, frequency, ______________
 other signs of pain _______________________
remedies) ______________
________________________________________
 Nocturia ______________
________________________________________
 Sleep difficulties ______________
 Denied ______________  side rail release form signed (60+ years) ______
________________________________________
COPING: Observed non-verbal behavior: ___________________
Occupation ____________________________________________
Members of household: __________________________ ____________________________________________
_____________________________________________ ____________________________________________
_____________________________________________ Person (Phone Number) ________________________
Most supportive person: _________________________ ____________________________________________
_____________________________________________
SPECIAL PATIENT INFORMATION (USE LEAD PENCIL)
________________ Daily Weight ________________ PT / OT
________________ BP Shift ________________ Irradiation
________________ Neuro VS ________________ Urine Test
________________ CVP / SG Reading ________________ 24 hour Urine Collection

Date Ordered Diagnostic / Laboratory Date Done Date I.V. Fluids / Blood Date Disc.
Exams Ordered

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 DRUG STUDY
Name of Patient: ___________________________
Specific
Dose /
Name of Drug Date Mechanism Indication Contra- Side Effects / Nursing
Classification Frequency
Generic (Brand) Ordered of Action (why drug is indication Toxic Effects Precaution
Route
ordered)

Score: __________ Grade: __________

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 NURSING CARE PLAN
Name of Patient: ___________________________
NURSING
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS

Score: _______________ Grade: ______________

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 HEALTH TEACHINGS

Name of Patient: _______________________________

MEDICATION

EXERCISE

TREATMENT

OUT-PATIENT
(Check-up)

DIET

Score: ____________ Grade: _____________

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