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ST.

ANTHONY’S COLLEGE
Nursing Department
San Jose, Antique

DELIVERY AND LABOR ASSESSMENT

I. VITAL INFORMATION
Name:
Age:
Address:
Civil Status:
Date and Time Admitted:
Chief Complaint:
Ward:
Bed No.:
Allergies:
Religious Affiliation:
Physician’s Initial:
Impression/Diagnosis:

II. CLINICAL ASSESSMENT


A. OBSTETRICAL DATA:
1. Age of Menarche:
2. G__ P__ (T__ P__ A__ L__ )
3. Description of Previous Pregnancies:
Pregnancies Type of Delivery Complications of Labor
and Delivery

4. LMP:
5. EDC:
6. Prenatal Check-up:
7. Description of Present Pregnancy:
8. Medications Taken During Pregnancy:
9: Discomforts on Present Pregnancy:

10. Progress of Labor:


Time Duration Frequency Intensity

11. Description of each stage of Labor (Textbook Discussion):


Stages of Labor Description

12. Type of Anesthetic Used:


13. Type of Episiotomy and Description:
14. Type of Delivery:
15. Type of BOW Ruptured:
16. Description of Placental Delivery:

B. GYNECOLOGIC HISTORY

C. FAMILY PLANNING PRACTICES

D. PAST HEALTH PROBLEMS/STATUS


a. Childhood Illness:
b. Childhood Immunizations:
c. Allergies:
d. Accidents and Injuries:
e. Hospitalizations for Serious Illness:
f. Medications:

E. FAMILY HISTORY OF ILLNESS

F. PATIENT’S EXPECTATIONS
Towards Hospitalization:

Towards Nursing Care:

G. PATTERNS OF FUNCTIONING
a. Breathing Patterns
Respiratory Problems:
Usual Remedy:
Manner of Breathing:

b. Circulation
Usual Blood Pressure:
Any history of chest pain, palpitations, coldness of extremities, etc.:

c. Sleeping Patterns
Usual Bedtime:
No. of Pillows:
Bedtime Rituals:
Problems regarding sleep:
Usual Remedy:

d. Drinking Patterns
Total amount of fluid intake/day:
Kinds of fluid usually taken:

e. Eating Patterns

Usual Food Taken Time


Breakfa
st
Lunch
Snacks
Dinner

Food likes:
Food dislikes:

f. Elimination Patterns
1. Bowel Movement
Frequency:
Problems/Difficulties:
Usual Remedy:

2. Urination
Frequency:
Problems:
Usual remedy:

g. Exercise

h. Personal Hygiene
1. Bath
Type
Frequency:
Time of Day:

2. Oral
Frequency of Brushing:
Care of Dentures:

3. Shaving
Frequency:

4. Use of Cosmetics

i. Recreation
j. Health Supervision

H. BRIEF SOCIAL, CULTURAL AND RELIGIOUS BACKGROUND


a. Educational Background:

b. Occupation:
c. Religious Practices:
d. Persons Significant to the Patient:
e. Social Role:
f. Economic Status:

g. Home and Neighborhood Conditions:

h. Lifestyle:

J. CLINICAL INSPECTION
1. Vital Signs
Date and Time Taken:

T=
PR =
RR =
BP =

2. Height:
3. Weight:
4. Physical Assessment

General Appearance:
a. Skin
b. Etc ….