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SOUTHEASTERN LOUISIANA UNIVERSITY School of Nursing-NLAB 473 Intrapartal Assessment Student: Name_____________________________________ Date__________ Patient: Age____ Ethnicity/Culture_____________ Language _________ Physiological: Past Medical History: Diabetes, Heart disease, hypertension, anemia, STD’s, others ____________________________________________________________________ Allergies_____________________________________________________________ _ Family genetic history: cleft lip or palate, trisomy 21, twins, etc. ________________ OB history: GTPAL: ___/___/___/____/___ GP __/___ Dates of previous deliveries) include method of delivery, gestational age, and Complications.)___________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Current Pregnancy: Current T, ____P_____, R_____, B/P________ Information from Prenatal Record if available: Height_________, Weight at last visit____________, Fundal height (at last visit)__________LMP ________ EDB________Ultrasound date_______ Date of first prenatal visit____________Number of visits_________ BASELINE B/P (at last visit)____________ Presence of symptoms throughout current pregnancy: nausea, vomiting, vaginal bleeding, abdominal cramping, burning on urination, edema of extremities, headaches, blurred vision, rupture of membranes, elevated temperature, rigid and tender abdomen, 2 High Risk Factors: PIH, Gestational Diabetes, Placenta Previa, Teen pregnancy, Over 35, previous c/s, Anemia, Premature labor, Premature Rupture of membranes, Beta Strep other___________________________________________________ When did patient arrive in the labor unit? ___________ When did labor begin? ______________Signs and symptoms of beginning labor_____________________________________________________________ Membranes: Intact____ SROM ____ AROM ____ Time_______ Color__________ Describe the contraction pattern (frequency, duration, intensity) at time of initial assessment_________________________________________________________ Describe changes in the contraction pattern over the course of your care_________________________________ Describe the results of the initial vaginal examination (dilatation, effacement, station, presentation) _________________________________________________________ Describe the results of last vaginal exam (dilatation, effacement, station, presentation) Record history of fetal monitoring: External Ultrasound (US) Time began____________ Internal Scalp Electrode (ISE) Time began_________ Record history of contraction monitoring: External tocotransducer (toco) Time began_____________________ Internal intrauterine pressure catheter (IUPC) Time began___________________ Describe the fetal heart rate pattern: Location___________________________________________________ Baseline heart rate_________ _____ Accelerations: Yes No Type of decelerations if present: Early Variable Late IV site: ___________________________________________________________ Type of IV: Primary Solution, Amount, Rate________________________________ 3 Secondary Solution ___________________________________________ Medications________________________________________________________ Epidural: yes no Describe: Time started___________ Anesthetic used:_______________ Method of Delivery (i.e., Continuous on IV pump, syringe pump, or intermittent): _______________ Stage of Labor at time of admission: First stage: Latent phase, Active phase, transition phase Second stage Stage of Labor at time of assessment:__________________________________________ Safety Needs: What is the position of the patient? _________________________________ Are side rails up and is the bed in the locked position? Yes NO Is the nurse call device in reach of the patient? Yes NO Laboratory tests (if available; some of these may be obtained from the prenatal record): Hgb___ Hct___ WBC_____ Platelets_______Blood Type & Rh________ Rubella titer______Group B Strep Culture________HBV_____HIV____ Urine glucose and protein________ Urine toxicology screen ______ Others __________ Psychological: History (treatments or medications)__________________________________ Current psychological state (oriented, dressed appropriately, communicates appropriately, etc. )_______________________________________________ Mood or affect (happy, depressed, flat)_______________________________ Is support person needed or requested during labor and delivery? ___________ Social: Marital Status (circle one) Married, Separated, Divorced, Single Educational level____________ Use of : alcohol, drugs, smoking, other____________ Past experiences with childbearing ___________________________________________ 4 _______________________________________________________________________ Beliefs about: labor management _______________________________________ State personal preference for method of feeding infant. ______________________ Did patient and significant other attend childbirth education classes? Yes No Developmental Data: Identify the patient's stage of development by age: Industry vs. Inferiority (6-12); Identity vs. Identity Confusion (12-19); Intimacy vs. Isolation (20-35); Generativity vs. Self-Absorption (35 +). According to Erickson’s stages, is behavior appropriate for age? YES NO Spiritual: Religious preference________________ Rituals relevant to childbirth that health care providers should be aware of: ___________________________________ Contacts of spiritual advisors if needed_________________________________ Delivery: Date and time of delivery___________________ Sex _______ Apgar scores: 1 min___ 5 min___ Method of delivery: spontaneous vaginal___ assisted? forceps ___ vacuum___ C/S___ Estimated Blood loss________ MATERNAL COMPLICATIONS: perineal or vaginal tears______________________ Last recorded fetal heart tone rate__________ Maternal temp prior to delivery________ Medications administered in delivery _________________________________________ NEWBORN COMPLICATIONS: ___________________________________________ Apgar Scoring System 1 Minute Heart rate Respiratory effort Muscle tone Reflex irritability Color TOTAL SCORE 5 Minute 5 Was Resuscitation required? NO Yes If so, describe type: blow by oxygen, mask oxygen, positive pressure ventilation with ambu bag and oxygen, intubation, chest compressions. _______________________________________________________ Nursing Diagnosis: Identify at least five nursing diagnoses in ALL the patient domains (physiological, psychological, socio/cultural). List in order of priority. Revised spring 2016/ja