OBSTETRICAL ASSESSMENT

I. VITAL INFORMATION:

NAME: (Initial’s only)

AGE:
SEX
ADDRESS:
RELIGIOUS AFFILIATION:
ALLERGIES: (medication, food, pollens, or any
contact agent, etc.)
DATE OF DELIVERY:
TIME OF DELIVERY:
EDUCATIONAL ATTAINMENT:
CIVIL STATUS:
DATE & TIME ADMITTED:
PHYSICIAN’S INITIAL:
CHIEF COMPLAINT:
IMPRESSION/DIAGNOSIS:

INFORMANT: (Patient herself, etc.)

RELATIONSHIP TO PATIENT: (Patient’s son,
husband, etc.)
II. OBSTETRICAL HISTORY

G ___ P ____ T ____ P _____A _____ L ____

LMP: EDC:

MENARCHE:
CYCLE:
DURATION:
NO. OF PADS PER DAY:
TYPES OF DELIVERY:
NSVD ___ CESAREAN SECTION ___OTHERS ___
EPISIOTOMY: YES _______ NO _______
TYPE OF INCISION:
MEDIOLATERAL: RIGHT ___ LEFT ___
MEDIAN:
PREVIOUS MEDICAL EXPERIENCE: YES __ NO ___
DATE:
REASON FOR HOSPITALIZATION: (Cause, name of
hospital, how the condition was treated, how long the
person was hospitalized)
DATE OF LAST CONSULTATION WHILE
PREGNANT:
DID YOU RECEIVE ANY HEALTH TEACHINGS
REGARDING?
LABOR ______ POSTPARTUM ______
DELIVERY ______ NEWBORN CARE ______
DOES SHE DO ANY READING? YES ___ NO ___
IF YES, SPECIFY WHAT MATERIALS ARE BEING
READ:

ANY COMPLICATIONS DURING THIS

PREGNANCY/PREVIOUS PREGNANCY:
(History of bleeding, increased BP, GDM, etc.)
MEDICATIONS TAKEN DURING
PREGNANCY:

FAMILY PLANNING:
HAS FAMILY PLANNING BEEN
PRACTICED? YES _______ NO _______
METHOD OF CONTRACEPTION USED:
IF NO, SIGNIFIES WILLINGNESS TO
PRACTICE FAMILY PLANNING?
YES _______ NO _______
METHOD:
PREVIOUS PREGNANCY
LOCATION TYPE OF COMPLICATIONS DATE
DELIVERY
III. CLINICAL ASSESSMENT
III.A. NURSING HISTORY

1. HISTORY OF PRESENT ILLNESS

A. USUAL HEALTH STATUS
B. CHRONOLOGIC STORY (When started,
description of problem, location, character,
severity, timing, aggravating or relieving
factors, associated factors, client’s
perception of what the symptom means and
thus the admission)
C. RELEVANT FAMILY HISTORY

D. DISABILITY ASSESSMENT (Physical,

Social, Mental, Emotional)

2. FAMILY HISTORY OF ILLNESS (Illness in

family, mother, father, siblings – Heart
Disease, high blood pressure, diabetes,
blood disorders, cancer, arthritis, allergies,
obesity, alcoholism, mental illness, etc.)
3. PATIENT’S EXPECTATIONS
• WHAT SHE EXPECTS TO OCCUR DURING
HOSPITALIZATION
(patient’s or informant’s verbalization)

• REGARDING NURSING CARE

(patient’s or informant’s verbalization)
4. PATTERNS OF FUNCTIONING

A. BREATHING PATTERN
REPIRATORY PROBLEM: (difficulty of
breathing, asthma, etc.)
USUAL REMEDY: (positioning,
medications, etc.)
MANNER OF BREATHING:
(regular/irregular, silent, effortless, etc.)
B. CIRCULATION

USUAL BP:
HISTORY OF CHEST PAIN, PALPITATION,
COLDNESS OF EXTREMITIES:
PRESENCE OF EDEMATOUS AREA:
C. SLEEPING PATTERN

USUAL BEDTIME: (be specific, wake up time)

HOURS OF SLEEP:
NAP HABITS:
PROBLEMS REGARDING SLEEP:
USUAL REMEDY:
NO. OF PILLOWS: (where, size of pillow)
BEDTIME RITUALS: (bath, pray, etc.)
D. EATING PATTERNS
APPETITE WHILE PREGNANT:
DIET WHILE PREGNANT:
WEIGHT GAIN:
USUAL FOOD TIME

BREAKFAST: (How many cups of rice, size, how many pieces)

LUNCH:
SNACKS:
DINNER:
FOOD LIKES:
FOOD DISLIKES:
FOOD PREFERENCES:
E. ELIMINATION PATTERN

BOWEL MOVEMENT: (frequency)

CONSTIPATION: (consistency of stool)
USUAL REMEDY: (use of laxatives, increased
water intake, etc.)
BLADDER IRREGULARITIES: (urinary
frequency, retention, dysuria, complaints,
etc.)
F. REST AND ACTIVITIES

ACTIVITY DURING DURATION OF

PREGNANCY:
REST PERIOD DURING PREGNANCY:
EXERCISE DONE ON THE:
FIRST TRIMESTER:
SECOND TRIMESTER:
THIRD TRIMESTER:
G. HEALTH SUPERVISION (ANY PRENATAL
CONSULTATION DONE AND WITH
WHOM)
(Physician’s initial, where, what was done,
frequency of visits)
5. CLINICAL INSPECTION
A. VITAL SIGNS: DATE:
T= R=
P= BP=
B. HEIGHT:
WEIGHT:
C. GENERAL APPERANCE

(Orientation, Facial features, body stature,

nutrition, symmetry, posture, position, body
build/contour, mobility (gait, range of motion),
facial expression, mood and affect, clothing,
speech, personal hygiene, any contraptions
(IV cannula, IV fluid, O2 inhalation, etc.)
SKIN, HAIR, NAILS – Skin: color,
temperature, moisture, texture, thickness,
edema, mobility/turgor, vascularity, bruising,
lesions; Hair: Color, texture, distribution,
lesions, dandruff, pest inhabitants; Nails:
shape and color, color, capillary refill, etc.

HEAD, FACE & LYMPHATICS – Head/Face:

size and shape, temporal area, any
complaints of dizziness, facial features;
Lymphatics: Symmetry, Range of Motion,
lymphnodes, etc.
EYES, EARS, NOSE, THROAT, MOUTH –
Eyes: PERRLA, conjunctivae and sclera,
eyebrows, eyelids and lashes, eyeballs,
lacrimal status, visual acquity; Ears – size
and shape, symmetry, discharges/odor,
tenderness, redness, swelling, lesions,
hearing acquity; Nose: symmetry, patency,
discharges, deformity, nasal mucosa, nasal
septum, tenderness; Throat: uvula, tonsils,
Mouth: lip color, moisture, lesions, halitosis,
teeth and gums, tongue.
NECK & UPPER EXTREMITIES – Neck: symmetry,
ROM, lymph nodes, trachea, thyroid gland Upper
Extremities: Range of motion, symmetry of joints
and muscles, muscle strength (5/5), skin turgor and
mobility, capillary refill, deformities, edema,
temperature, moisture, lesions, presence of
contraptions

CHEST, BREAST, AXILLAE: Chest: expansion, use

of accessory muscles, rashes, pain, palpitations;
Breast: symmetry of size and shape, nipples,
discharges, color, temperature, engorgement,
tenderness; Axillae: color, redness, tenderness,
odor, perspiration, masses
THORAX, LUNGS, RESPIRATORY SYSTEM –
Thoracic cage and configuration, symmetric
expansion, Breath Sounds: Describe all auscultated
lung sounds/clear/decreased/absent, Adventitious:
rales/rhonchi/wheeze, Respiratory
rate/rhythm/depth/quality/effort of
breathing/dyspnea/SOB/cough

HEART & CARDIOVASCULAR SYSTEM - Apical

Pulse: rate/rhythm/quality, B/P: site/position; Pain:
location/frequency/duration/intensity on a scale of 0 -
10/provokes/palleates/quality/ radiates,
fatique/dizziness/chest pain/numbness/ tingling in
extremeties
ABDOMEN & GI SYSTEM - Abdomen: contour,
fundus, skin pigmentation,
soft/distended/tenderness/colostomy, lesions,
scars, hair distribution, Bowel Sounds: present/
absent, hyper/hypo active,
Continence/diarrhea/constipation, Last Bowel
Movement/consistency/color, Nausea/Vomiting

GENITALIA/ GENITOURINARY SYSTEM – skin

color, hair distribution, presence of lesions,
symmetry, vaginal discharges, presence of
episiotomy, swelling, bulging, urinary status,
hemorrhoids, tenderness, masses
LOWER EXTREMITIES/
MUSCULOSKELETAL SYSTEM –
Range of motion, symmetry of joints
and muscles, muscle strength (5/5),
skin turgor and mobility, capillary refill,
deformities, edema, temperature,
moisture, lesions
GENERAL APPRAISAL:

BODY BUILT: (Ectomorph, Mesomorph,

Endomorph)
SPEECH: (articulation, pace of the
conversation,etc.)
LANGUAGE: (Dialects and languages used)
HEARING: (hearing acquity)
MENTAL STATUS: (consciousness, oorientation,
attention, memory, perceptions, etc.)
EMOTIONAL STATUS: (cooperation, mood and
affect, facial expressions)
HANDICAPS & LIMITATIONS:

1. SOCIAL (Interaction with environment)

2. PHYSICAL (Need for Assistance with ADL's:
Bathing, Toileting, Dressing, Feeding,
Ambulating, Transferring , etc.)
IV. LABORATORY & DIAGNOSTIC
PROCEDURES

1. CLINICAL CHEMISTRY:
NAME OF EXAMINATION:
DEFINITION:
PURPOSE:
RESULTS:
DATE:
COMPONENTS RESULTS NORMAL VALUES SIGNIFICANCE
2. NAME OF EXAMINATION: URINALYSIS
DEFINITION:
PURPOSE:
RESULTS:
DATE:

RESULT NORMAL SIGNIFICANCE

3. NAME OF EXAMINATION: HEMATOLOGY
DEFINITION:
PURPOSE:
RESULTS:
DATE:

COMPONENTS RESULTS NORMAL VALUES SIGNIFICANCE

4. RADIOLOGICAL EXAMS AND OTHER
SPECIAL EXAMS:
NAME OF EXAMINATION:
DEFINITION:
PURPOSE:
RESULTS:
DATE:
IMPRESSION:

SIGNIFICANCE:
V. TEXTBOOK DISCUSSION:
A. DIAGNOSIS:

PATHOPHYSIOLOGY:
B. DEFINITION:

C. S/Sx FOUND IN THE BOOK MANIFESTED BY PATIENT

D. SCHEMATIC DIAGRAM

MEDICAL MANAGEMENT:
NURSING MANAGEMENT:
HEALTH TEACHINGS: (DISCHARGE
PLANNING)
ON-GOING APPRAISAL

DATE:
TIME:

S-
0-
A-
P/I-
E-
R-
PROBLEM LIST:
1.
2.
3.
4.
5.

NURSING CARE PLAN (SEE ATTACHED

SHEET)
DRUG STUDY (SEE ATTACHED SHEET)
 NURSING CARE PLAN
Name of Patient: ______________ Attending Physician: _________
Age: ________ Ward/Bed Number: ______
Impression/Diagnosis: ____________________________________
Clustered Cues Nursing Rationale Objectives of Care/ Nursing Rationale Evaluation
Diagnosis (Scientific Basis) Outcome Criteria Interventions (Scientific Basis)
(Subject+Verb+
Condition+ Criteria +
Target Time)

Student’s Name: ______________________________________

Clinical Instructor: _____________________________________
 DRUG STUDY
Name of Patient: ______________ Attending Physician: _________
Age: ________ Ward/Bed Number: ______
Impression/Diagnosis: ____________________________________
Name of Drug Dosage, Mechanism Indication Adverse Special Nursing
Route, of Action Reactions Precautions Responsibilities
Frequency,
Timing

Generic: Dosage:

Brand: Route:

Classification Contraindications Side Effects

Functional: Frequency:

Chemical: Timing:

Student’s Name: ______________________________________

Clinical Instructor: _____________________________________