Metropolitan Community College
Nursing 2410
OB Assessment
Date:____________
Student:__________________
Prenatal History (Review from chart)
Client initials ______ Age _____ Allergies ______________________________
Weeks Gestation ______ EDC _____ G_____ T_____ P _____ A _____ L _____
Pre-Pregnancy Weight _________ Current or Admission Weight ___________
Blood type & RH _____________ Rhogam Given? Y / N
Rubella ________ Serology (VDRL) __________ Hepatitis (HbsAg) _________
GBS _________ HIV ________ Herpes _________ GC/Chlamydia __________
Pre-existing medical conditions:
Family medical history:
Complications with previous pregnancies or deliveries:
Risk Factors from prenatal history (physical, emotional, socioeconomic and/or
developmental):
Support person _______________________ Relationship ___________________
Home medications (prescribed, OTC, Illicit):
Alcohol _____ # of drinks a day _____ Smoker _____ # of cigarettes a day_____
Intrapartum
Physical Assessment
Pain Assessment
Neurological Assessment
Location of Pain:
Oriented to:
Intensity of Pain:
Disorientated to: Person Place Time
Event
Person
Place
Time Event
Pain Scale: 1 2 3 4 5 6 7 8 9 10
Interventions: ________________________
_____________________________________
(Pain is charted every two hours and reassessment of pain
after intervention is 30 min.)
Headache Dizziness Blurry Vision
Deep tendon reflexes :
Clonus:
Homans:
Pain Comments: _______________________________________________________________
_____________________________________________________________________________
Neurological Comments: ________________________________________________________
_____________________________________________________________________________
Musculoskeletal Assessment
Cardiovascular Assessment
History of Falls: Yes
Rhythm:
No
ROM: Limited
Full
ROM: Active
Passive
Strength:
Strong
Regular
Contracted
Weak
Hand Grasps:
Left:
Strong
Right: Strong
Weak None
Weak None
Leg Movement:
Left:
Strong
Right: Strong
Weak None
Weak None
Murmur:
Regular-Irregular Irregular-Regular
Yes
No
Fatigues easily
Capillary Refill:
LUE: <2 sec
RUE: <2 sec
LLE: <2 sec
RLE: <2 sec
<3 sec
<3 sec
<3 sec
<3 sec
>3 sec
>3 sec
>3 sec
>3 sec
>5 sec
>5 sec
>5 sec
>5 sec
Radial Pulse:
Fall Risk: __________________
Additional Comments:
Left: Strong Weak Present with Doppler Absent
Right: Strong Weak Present with Doppler Absent
Pedal Pulse:
Left: Strong Weak Present with Doppler Absent
Right: Strong Weak Present with Doppler Absent
Integumentary Assessment:
Color: Normal for Race Cyanotic
Pale Other (describe)
Temperature:
Warm Cool
Skin: Dry Moist
Clammy
Other (describe):
Flushed
Edema: Present
LUE: 1+ 2+ 3+
RUE: 1+ 2+ 3+
LLE: 1+ 2+ 3+
RLE: 1+ 2+ 3+
Not Present
4+ Pitting
4+ Pitting
4+ Pitting
4+ Pitting
Weeping
Non-Pitting
Non-Pitting
Non-Pitting
Non-Pitting
Additional Comments:
Respiratory Assessment
Gastrointestinal Assessment
Rhythm:
Bowel Sounds:
RUQ: Normal Hypoactive
RLQ: Normal Hypoactive
LUQ: Normal Hypoactive
LLQ: Normal Hypoactive
Regular
Irregular
Effort: Labored
Unlabored
Dyspnea on Exertion
Rate:
Tachypnea
SOB
Bradypnea
Apnea
Lung Sounds:
Hyperactive
Hyperactive
Hyperactive
Hyperactive
Absent
Absent
Absent
Absent
BM: Date of Last: _____________________
Abdomen: Soft Firm Round Tender
Non-tender
Mode of Elimination: Bedpan BSC BR
Anterior:
LUL________________________________
RLL________________________________
RML_______________________________
Urinary Assessment
LUL________________________________
Voiding: No difficulty Hesitancy
Frequency Unable to Void
LLL________________________________
Posterior:
RUL________________________________
Color: __________Appearance:___________
RLL________________________________
Mode of Elimination:
BRP
BSC
Bedpan
Foley/Other Catheter
LUL________________________________
LLL_________________________________
Other: Stridor
Rub
Other:______________
Additional Comments:
Environmental Safety
Side rails: Down
1 Up 2 Up
Bed Position:
Low High
Pelvic Assessment
Discharge:
Color:
ROM: Spontaneous
3 Up
4 Up
Bed Locked:
Yes
Color:
Odor:
No
Odor:
Artificial
Date/Time:________
Bleeding:
Dilation:
Date and time contractions started:
Anesthesia: Epidural____ Spinal____ General_____ Local_____ Pudendal_____
Stage of Labor
Pain Rating
Strength of Uterine
Contraction
Client Behavior
Comfort Measures &
Effectiveness
Stage 1
Phase 1
Early Labor
Stage 1
Phase 2
Active Labor
Stage 1
Phase 3
Transition
Stage 2
Pushing
Stage 3
Delivery to Placenta
Stage 4
Recovery Period
Strip Evaluation
Time or stage
FHR baseline
Variability
Accels/Decels
Uterine Activity
Freq/Dur/Int
Comments
Delivery Information
Type of delivery:
Delivery of Placenta: Spontaneous
Date/Time:
Manual
Retained
Time:
Episiotomy / Lacerations / Extensions / Incisions____________________
EBL:
Interventions to assist with delivery:
Sex of Infant____________ Apgars: 1 min_____5 min_____ 10 min_____
Resuscitation:
Ht:____________ Wt:_____________
Medications (Including anesthesia) given during the labor process:
Postpartum Assessment
Maternal Physical Assessment
Pain Assessment
Neurological Assessment
Location of Pain:
Oriented to:
Intensity of Pain:
Disorientated to: Person
Pain Scale: 1 2 3 4 5 6 7 8 9 10
Event
Headache Dizziness Blurry Vision
Deep tendon reflexes :
Clonus:
Homans:
Interventions: ________________________
_____________________________________
(Pain is charted every two hours and reassessment of pain
after intervention is 30 min.)
Person
Place
Time Event
Place Time
Pain Comments: _______________________________________________________________
_____________________________________________________________________________
Neurological Comments: ________________________________________________________
_____________________________________________________________________________
Musculoskeletal Assessment
Cardiovascular Assessment
History of Falls: Yes
Rhythm:
No
ROM: Limited
Full
ROM: Active
Passive
Strength:
Strong
Regular
Contracted
Murmur:
Weak
Regular-Irregular Irregular-Regular
Yes
No
Fatigues easily
Hand Grasps:
Left:
Strong
Right: Strong
Weak None
Weak None
Leg Movement:
Left:
Strong
Right: Strong
Weak None
Weak None
Capillary Refill:
LUE: <2 sec
RUE: <2 sec
LLE: <2 sec
RLE: <2 sec
<3 sec
<3 sec
<3 sec
<3 sec
>3 sec
>3 sec
>3 sec
>3 sec
>5 sec
>5 sec
>5 sec
>5 sec
Radial Pulse:
Left: Strong Weak Present with Doppler Absent
Right: Strong Weak Present with Doppler Absent
Fall Risk: __________________
Additional Comments:
Pedal Pulse:
Left: Strong Weak Present with Doppler Absent
Right: Strong Weak Present with Doppler Absent
Integumentary Assessment:
Color: Normal for Race
Pale Other (describe)
Cyanotic
Temperature:
Warm Cool
Skin: Dry Moist
Clammy
Other (describe):
Flushed
Edema: Present
LUE: 1+ 2+ 3+
RUE: 1+ 2+ 3+
LLE: 1+ 2+ 3+
RLE: 1+ 2+ 3+
Not Present
4+ Pitting
4+ Pitting
4+ Pitting
4+ Pitting
Weeping
Non-Pitting
Non-Pitting
Non-Pitting
Non-Pitting
Additional Comments:
Respiratory Assessment
Gastrointestinal Assessment
Rhythm:
Bowel Sounds:
RUQ: Normal Hypoactive
RLQ: Normal Hypoactive
LUQ: Normal Hypoactive
LLQ: Normal Hypoactive
Regular
Irregular
Effort: Labored
Unlabored
Dyspnea on Exertion
Rate:
Tachypnea
Bradypnea
SOB
Apnea
Lung Sounds:
Hyperactive
Hyperactive
Hyperactive
Hyperactive
Absent
Absent
Absent
Absent
RLL________________________________
BM: Date of Last: _____________________
Abdomen: Soft Firm Round Tender
Non-tender
Mode of Elimination: Bedpan BSC BR
RML_______________________________
Flatus: Yes/No
Anterior:
LUL________________________________
LUL________________________________
Urinary Assessment
LLL________________________________
Posterior:
Voiding: No difficulty Hesitancy
Frequency Unable to Void
RUL________________________________
RLL________________________________
Color: __________Appearance:___________
LUL________________________________
Mode of Elimination:
BRP
BSC
Bedpan
Foley/Other Catheter
LLL_________________________________
Other: Stridor
Rub
Other:______________
Additional Comments:
Environmental Safety
Side rails: Down
1 Up 2 Up
Bed Position:
Low High
3 Up
4 Up
Bed Locked:
(B) Breasts: Tender / Non-tender / Cracked / Filling / Not filling
(U) Uterine Involution: Firm / Firm with massage / Boggy
Location:
(B) Bowel (Bowel sounds; Flatus):
(B) Bladder (voiding, distention, incontinence):
(L) Lochia (amount, color):
(E) Episiotomy:
(H) Homans:
(E) Emotional Status:
Other (include abd incision assessment if c/s):
Yes
No
Parent/Infant Interactions
Verbal and Nonverbal responses of parents:
Verbal and Nonverbal responses of family members:
Knowledge deficit(s):
Resources:
Infant Data:
Birth Weight_______ Daily Weight_______ Length______ Head Circumference: ________
Feeding method: Breast
First void: Yes / No
Neonatal Labs:
Cord PH:
Chemstrip:
Coombs:
Billirubin:
Blood Type:
/
Formula
Date:______ Time:_______
Interpretation:
Intake/Output (List all feedings, stools, voids, emesis during your shift)
Time Feeding
Amount
Void
Stool (color &
Emesis Comments
Type
consistency)
Infant Physical Assessment
Assessment
List Infant Findings
Vital Signs
Pulse, Respirations, Cry,
Temperature
Posture
Flexion, Symmetry,
Activity, Sleep
Skin
Color, Texture, Turgor,
Pigmentation, Rashes,
Petechiae, Lesions
Head
Size, Shape, Movement,
Symmetry, Fontanels,
Sutures
Hair
Texture, Distribution
Face
Symmetry & Presence of
Facial Features, Spacing of
Features, Movement
Eyes
Placement, Appearance,
Eyelids, Movement, Edema,
Cornea, Sclera, Pupils,
Conjunctiva, Vision, Lashes
& Glands
Nose
Appearance, Patent Nares
Mouth
Symmetry of Movement,
Gag, Swallow, Palate,
Tongue
Ears
Appearance, Placement,
Hearing
Neck
Appearance
Clavicles
Chest
Appearance & Size,
Expansion & Retraction,
Auscultation, Breasts,
Nipples
Heart
Auscultation, PMI,
Murmurs, Thrills
Abdomen
Appearance, Cord
(Arteries/Vein), Bowel
Sounds, Femoral Pulses,
Inguinal Area, Bladder
Genitalia
Male: Penis, Scrotum,
Testes
Female: Mons, Clitoris,
Vagina, Discharge
Buttocks & Anus
Symmetry, Patency
Extremities & Trunk
Flexion, Symmetry of
Movement/Strength, Arms,
Hands, Spine, Hips,
Inguinal & Buttock Skin
Creases, Legs, Feet
Neuromuscular
Symmetry of Movement,
Head Control
Reflexes
Blink
Moro
Rooting/Sucking
Palmar Grasp
Plantar Grasp
Babinski
Tonic Neck
Trunk Incurvation
(Galant)
Nursing Diagnosis (mom) Priority #______________:
Diagnosis:
R/T (etiology):
AEB: (subjective and objective date)
Goal:
Intervention (minimum of 5)
Evaluation: (was goal met or not, list reasons for your decision)
Scientific Rationale
Nursing Diagnosis (mom) Priority #______________:
Diagnosis:
R/T (etiology):
AEB: (subjective and objective date)
Goal:
Intervention (minimum of 5)
Evaluation: (was goal met or not, list reasons for your decision)
Scientific Rationale
Nursing Diagnosis (mom) Priority #______________:
Diagnosis:
R/T (etiology):
AEB: (subjective and objective date)
Goal:
Intervention (minimum of 5)
Evaluation: (was goal met or not, list reasons for your decision)
Scientific Rationale
Nursing Diagnosis (infant) Priority #______________:
Diagnosis:
R/T (etiology):
AEB: (subjective and objective date)
Goal:
Intervention (minimum of 5)
Evaluation: (was goal met or not, list reasons for your decision)
Scientific Rationale
Nursing Diagnosis (infant) Priority #______________:
Diagnosis:
R/T (etiology):
AEB: (subjective and objective date)
Goal:
Intervention (minimum of 5)
Evaluation: (was goal met or not, list reasons for your decision)
Scientific Rationale
Nursing Diagnosis (infant) Priority #______________:
Diagnosis:
R/T (etiology):
AEB: (subjective and objective date)
Goal:
Intervention (minimum of 5)
Evaluation: (was goal met or not, list reasons for your decision)
Scientific Rationale