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: ____________________________________________________________
1
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 ________________
2
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:
3
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
4
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: __________
5
NURSING CARE PLAN
Name of Patient: ___________________________
NURSING
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Score: _______________ Grade: ______________
6
HEALTH TEACHINGS
Name of Patient: _______________________________
MEDICATION
EXERCISE
TREATMENT
OUT-PATIENT
(Check-up)
DIET
Score: ____________ Grade: _____________
7
