Running Head: OBSTETRIC ASSESSMENT
1
Obstetric Assessment
Katelynn Jurek
10-15-12
OBSTETRIC ASSESSMENT
FERRIS STATE UNIVERSITY
DEPARTMENT OF NURSING
OBSTETRIC HISTORY & PHYSICAL EXAM FORM
Student ___Katelynn Jurek________________ Date ___10-1-12_______________
Please review GUIDELINES FOR NURSING HISTORIES before beginning.
BIOGRAPHICAL DATA A. Pt. init. _R.S_____ Age _22_ DOB _9-5-90__ Religion _Christian__ Race
_Caucasian_____
B. Marital status (check one) Single X Married
Separated
Divorced
Widowed
C. Nearest relative/support person (relationship only) ___Mother________
BRIEF SOCIAL HISTORY
A. Where employed _Self-employed, watch children at home__ Occupation__No_____
B. Highest education _Some college____________
CURRENT PREGNANCY
A. Expected date of delivery _11-25-12__ Gravida ___2_____ Para ____0____ Ab ___1_____
B. Type of childbirth preparation: breastfeeding and birthing classes
Date last seen by Dr. __Sept. 12____
C. Allergies/sensitivities _____Everything airborne, pets, pollen _____
D. Special problems this pregnancy and treatment _______None______
E. Laboratory assessment (if known):
Blood type __A+____ Father’s blood type ___Unknown__
Anemia? _Iron_______
F. Nursing assessment:
Pre-pregnant Wt _205__ Present Wt _212__ Ht _5’9”_____
OBSTETRIC ASSESSMENT
G. Minor Discomforts (check all that apply):
x Mood Swings
x
Nocturia
X
Pain(where)
Dyspareunia
Fatigue
Leg cramps
Constipation
Itching of skin and
vulva
Frequent
Urination
Other:
Lower,
left
abdomen
x
Backache
x
Numbness or
swelling of feet,
fingers, ankles
x
Heart burn
x
x
Vaginal Discharge
x
Varicosities
Insomnia
x
Have you had or been exposed to a major
infection? (When)
Anxiety
(what)
IV. PAST HEALTH AND MENSTRUAL HISTORY
Write in this space pertinent information related to residual or chronic illness.
Pt. Pt. is diagnosed with osteoarthritis, degenerative disk disease, herniated disks, bulging disk, and
stretched spinal
cord.____________________________________________________________________
Last X-rays _January___ Type ____Back__________
What medications and vitamins are you taking and why?
Iron supplement because of the anemia.
V. Past Contraceptive History
x
Oral
Norplant
X
IUD
Gels & foams
Condoms
DEPO Provera
A. Previous Pregnancy History
Rhythm
OBSTETRIC ASSESSMENT
DOB
Sex
Birthweight
Living
Prem/FT/Stillborn
NA
NA
NA
B. Previous children with problems after birth? Explain ________NA_________________
____________________________________________________________________
____________________________________________________________________
C. Problems with previous pregnancies (excessive vomiting, multiple births, excessive wt.
gain, closely spaced pregnancies, etc.) Explain _______NA________________________
_____________________________________________________________________
D. Problems with previous labors and/or deliveries (extended labor periods, excessive
bleeding, abnormal fetal position, etc.) Explain ___________NA____________________
_____________________________________________________________________
E. Postpartum problems (sub-involution, infection, excess bleeding, bladder, etc.)
Explain __________________________NA____________________________________
VI. DIET ASSESSMENT
No. of meals per day __3__ No. of snacks per day __5__ Fluid intake per day _1.5 liters water and 2
glasses of milk___
Pica ___None_____
Peculiarities (social-cultural, religious, economic, etc.
None___________
Typical Daily Food Intake in 24-hr period
Breakfast
Food/Amount
Cereal/ 2 cups
Lunch
Food/Amount
Salad with ham
Dinner
Food/Amount
Meat/ 5 oz
Pasta/ 1 cup
Snacks
Food/Amount
fruit
OBSTETRIC ASSESSMENT
NUTRITION LIMITATIONS
What do you consider to be your healthy weight? __180__________
Do you eat at least 3 meals a day? yes
Are you on a special diet? no
Do you take folic acid? no
Do you have current or past problem with an eating disorder? no
Do you have any dental problems? no
When was your last check up? ____Sept 12________
Do you have any vision problems? no
Can you hear without problems? yes
Do you have any speech problems? no
Do you have any learning problems? no
Do you have any physical limitations? no
FEARS/ANXIETIES ABOUT PREGNANCY AND PARENTING
Personal Health: No
Personal Safety: No
Fetal Condition: No
Early Pregnancy Loss: Yes, because of miscarriage before
Pregnancy Complications: No
Hospital: No
Surgery: No
Anesthesia: No
Perinatal Loss: No
OBSTETRIC ASSESSMENT
Labor/Delivery: Yes, for the pain.
Infant Illness: No
Infant Attachment: No
Parenting Skills
A. Perception and knowledge of pregnancy and delivery (in client’s own words)
__Classes, I have as much knowledge as who hasn’t have a baby________________
B. Attitude toward pregnancy __
Not a big fan, I used to think it was beautiful. I want my body back. I feel selfish.
C. Questions asked by mother-to-be _No questions______
WORK/SCHOOL ACTIVITIES EXPOSURE
Have you experienced the loss of a co-worker and/or friend at work or school? No
Have you been threatened recently at work or school? No
Have you been involved in an argument or fight at work or school? Yes
Have you recently changed jobs? Yes
Have you recently changed school? No
Quit school? No
Do you use heavy equipment? No
Do you work long hours? No
Do you do heavy housework? No
Do you often stand for 30 minutes or more at a time? No
Do you often lift more than 20 pounds? No
Do you have problems climbing stairs? Yes
Do you play sports? No
Do you ride in a car more than 1 hour a day? No
Do you have a disability that limits activity? Yes, my back
OBSTETRIC ASSESSMENT
Are you exposed to:
Paint thinners or oven cleaners? No
Strong cleaners? No
Cat litter? No
Mercury or lead? No
Ceramics, stained glass, or jewelry making products? No
Have you eaten raw or uncooked meat? No
Do you wear your seat belt? Yes
How many sexual partners have you had in the past year? __2___
Are you now using/taking or have you ever taken/used hard drugs? ___No_____
Which one(s)? ________________________________________________________
Amount _________________________ Frequency __________________________
How many cigarettes do you smoke daily? ___Less than 1__ Any marihuana? ____Previously before
pregnancy__________
Do others smoke around you? Yes, cigarettes
How much alcoholic beverage do you drink per day/week? ____None________________
HOUSEHOLD SOCIAL SUPPORT RESOURCES
How many children do you care for in your home? 2 that I babysit . 44 hours a week
Ages: ____5 months and 3 yrs old____________
Do you care for a family member with a disability? No
Do you have a serious illness? No
Recent or planned move? July 2012
Do you feel sleepy or tired a lot? Yes
Do you feel safe where you live? Yes
Do you or anyone in your house ever go to bed hungry? No
Do you have any problems that keep you from health care appointments? No
OBSTETRIC ASSESSMENT
Do you have family who will help you? My mom
Do you have friends you can count on when you need help? Yes
Are you not getting along with or arguing with your: Getting along with everyone
Partner
Parent
Friends
Child
Other ________________
Do you have a car or access to transportation? Yes
Do you have access to a telephone? Yes
Do you receive:
Food Stamps: Yes
TANF/Welfare: Yes
Help with Child Care: Yes
Help with housing: Yes
WIC: Yes
INFORMATION ON BABY’S FATHER
Do you know for certain whom the father of the baby is? Yes
If yes, what is the age of the baby’s father? ___22_____
Is the baby’s father here with you today? No
How long have you known the baby’s father? __ 7 years______
Is the baby’s father happy about your pregnancy? No
Do you currently live with the baby’s father? No
Are you married to the baby’s father? No
Is the baby’s father currently married to someone else? No
OBSTETRIC ASSESSMENT
Does the baby’s father have children not in the home? Yes
If yes, how many children does he have? ___1___
What is his/her age? __2 yrs______
How long have you known your partner? __6 yrs______
Is he/she happy about your pregnancy? Yes
Does your partner have children not in the home? No
If yes, how many does he/she have? ________
LIFE STRESSORS MENTAL HEALTH VIOLENCE/ABUSE
Was your pregnancy planned? No
Do you want to parent this child? Yes
Do you have enough money to pay for food, housing, & bills? Yes
Have you recently experienced an extremely stressful event (house fire, tornado, death)? No
Do you feel overwhelmed, sad, hopeless, or lost pleasure in the things usually enjoyed? No
Are you having any problems sleeping? No
Have you recently thought about suicide? No
Have you ever attempted suicide? When? ____No________
Have you ever been diagnosed with a mental health condition? Depression
Have you been hospitalized for a mental health condition? No
Did you attend or currently attend mental health counseling? Yes, Catholic social services. Once per
week when she was 12-14 years old
Are you ever afraid of your partner? No
In the last year, has anyone at home hit, kicked, punched, or otherwise hurt you? No
In the last year, has anyone at home often put you down, humiliated you or tried to control what you
can do? No
In the last year, has anyone at home threatened to hurt you? No
Have you in the past or recently been a victim of:
OBSTETRIC ASSESSMENT
Rape/Sexual Assault? No
Past Recent
Mental Abuse? No
Past Recent
Crime Victim? No
Past Recent
Have you ever been investigated for hurting or neglecting a child? No
BABY’S FATHER OR CURRENT PARTNER IN THE HOME
Does the baby’s father or your current partner use:
Tobacco? Yes
Alcohol? Yes
Marijuana? Yes
Cocaine? No
IV Drugs? No
Meth? No
Is he bi-sexual? No
Does he have multiple partners? No
Is the baby’s father or your current partner employed? Yes
VII. PHYSICAL ASSESSMENT
General Appearance (DO NOT put “good” or WNL):
Her general appearance appeared that she doesn’t take extra care of herself. She was wearing
sweats, hair not done, no makeup. She appeared to be in early pregnancy due to her small weight gain.
She didn’t have the pregnancy glow and appeared to me as looking “stressed.” She was her usual
upbeat self and didn’t appear to be depressed.
OBSTETRIC ASSESSMENT
Educational Needs/Interventions
On the basis of your assessment, list at least TWO nursing diagnoses for your patient, interventions (min
3/nursing diagnosis), assessments for each nursing diagnosis, and the rationale for your actions. Please
have supporting evidence from the literature for your plan. Be sure your assessment and interventions
correspond to your Nursing Diagnosis.
Nursing Diagnosis
Fatigue r/t hormonal, metabolic,
body changes
(Ladwig & Ackley, 2011)
Fear r/t labor and delivery
(Ladwig & Ackley, 2011)
Interventions
1. Assess severity on a
scale of 1-10. Assess
frequency of fatigue and
activities and symptoms
associated with fatigue
2. Evaluate nutrition and
sleeping, (naps during
the day, inability to fall
asleep at night, or stay
asleep.) Encourage
routine sleep/wake
schedule, limit caffeine,
and eat well balanced
diet.
3. Help client to identify
sources of support and
essential and
nonessential tasks that
can be delegated to
whom.
Rationale
1. If it is just slight fatigue and is
brought on after physical
activity, than it isn’t alarming.
But if it is severe and all the time
than maybe some tests need to
be done to see if there is
anything that needs attention.
2. Knowing she has iron
deficiency anemia than it be
concluded that she may have
additional fatigue from low iron.
“Iron is a part of hemoglobin
which carries oxygen from lungs
to body.” “Iron deficiency
anemia during pregnancy can
increase risk for small or early
(preterm) babies. Small or early
babies are more likely to have
health problems or die in the
first year of life than infants who
are born full term and are not
small.” (Stoppler, 2011)
3. If there are difficult tasks to be
done and may be too tiring for
her, maybe she can have her
partner do it.
1. Assess source of fear
1. Assessing what the source is
with the client.
can determine what needs to be
2. Stay with clients when
addressed and possibly educated
they express fear.
on.
Provide verbal and
2. Comforting is very important
nonverbal reassurances. and if the patient has no one
3. Discuss the situation
else with them they need some
with the client to explore reassurance that it will be ok and
underlying feelings that
that they will get through it.
may be contributing to
3. Talking about the fear will
the fear.
help clear up any misconceptions
and talking about it before hand
OBSTETRIC ASSESSMENT
Deficient knowledge r/t
primiparity
(Ladwig & Ackley, 2011)
1. Provide visual aids to
enhance learning.
2. Consider the clients
ability and readiness to
learn when teaching
clients.
3. Monitor how client
processes information
over time.
will help them when the
situation presents itself.
1. Videos are great visual
aids to use. “Learning
something through
pictorial motion is
psychologically a
pleasant sensation to
many of us.” Also, “film
should not replace
discussion, rather it
should be
supplemental.” (Bennell,
2009).
2. If she is unwilling to
learn than it would be
unnecessary to spend a
lot of time teaching.
3. Monitoring her learning
is important because
maybe she needs a little
more in one area and
maybe she hasn’t
remembered everything
and needs a refresher.
OBSTETRIC ASSESSMENT
References
Bennell, F. B. (2009). Audio-visual Aids in Health Education. Journal of School Health, 1.
Ladwig, G. B., & Ackley, B. J. (2011). Guide to Nursing Diagnosis. Maryland Heights: Elsevier.
Stoppler, M. C. (2011, May 4). Iron and Iron Deficiency. Retrieved from Medicinenet:
http://www.medicinenet.com/iron_and_iron_deficiency/article.htm