Situation Background Assessment Recommendation
Situation:
Age: ________
Admitting Diagnosis: ___________________________
OB: ___________________ Pediatrician: __________________________
Background:
Gravida: ______ Para: ______ Term: ______ Preterm: ______ Abortion: ______ Living: _______
EDC: _________Gest Age: ________ Allergies: ____________________________________________
Medical/Surgical Hx: __________________________________________________________________
Family/Social Hx: __________________________ Pregnancy Hx: ______________________________
Delivery:
AROM/SROM Date:_______@________
Fluid: Clear/Meconium- thin/thick
Delivery Date:_________@__________
SVD ____ Forceps _____ Vacuum_____
C-Section ______ Indication:_____________
Tubal: Y/ N
Epidural ______ Removed _____
Blue tip_______ Band-Aid on _____
Infant:
Male:_____ Female:_______
Weight:______lbs ________oz _________grams
Length: _________cm __________in
APGARS: ______/_______/_______
Dubowitz:_______ LGA/AGA/SGA
Voiding: ______ Stooling:_______
Breast: _______ Bottle: ________
Infant Labs:
Blood Type: ______ Rh: ______ Coombs:______
EBL:_____ QBL:_____/________ Total:______
Recovery Medication:
Pitocin
Cytotec
Methergine
Hemabate TXA
Blood
Maternal Labs:
Blood Type:_________
Rubella: Immune (Pos) Non-Immune (Neg)
Hep B: Positive Negative
RPR: Reactive Nonreactive
GC: Positive Negative
Chlamydia: Positive Negative
HIV: Positive Negative 1st& 3rd Trimester:___
Herpes: Positive Negative Treated?____
UDS: Negative Positive _________
GBS: Positive Negative Unk
Treated x______doses
Abx given:____________
Last Dose @ _________
Glucose: _______
Admit H & H _______/________
Platelets: _______
PP H & H: ________/_______
Perineum/Incision:
Fundus: ________ (Midline/ Deviated Firm/ Boggy)
Lochia Rubra: Scant/ Minimal/ Moderate/ Heavy
Vaginal Laceration: 1/2/3/4
Location:________
Episiotomy: 1/2/3/4 Medial R/L Lateral
Hematoma: Size______ Edema: ________
C/S Incision: Sutures/Staples/Dermabond
C/S Dressing: C/D/I Remove @_______
Ice Pack: ______
Dermaplast:______ Tucks:_____ Sitz: _______
Maternal Nursing Care:
IV: Infusing / Saline Lock/ D/C
Voiding: ________ C/S Foley D/C:_________
Activity:_________ PP Diet: __________
Medications:
List All Scheduled and PRN Medication with
indications (No Med Sheet Required)
Flu Shot
Rubella
TDAP
Rhogam