Download Intrapartum File - selu moodle - Southeastern Louisiana University

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,
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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________________________________
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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 ___________________________________________
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_______________________________________________________________________
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