Beruflich Dokumente
Kultur Dokumente
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EDD: ________________________________________________ or masses on both breasts: _______ axillary lymph node mass:
History of Present Condition: (Start, list and describe symptoms _____ tenderness: __________
chronologically from time/day of onset onwards) d.) Abdomen: (minimal) gravidarum striae: _______
Initial: Wt: ________ (protruded) umbilicus______ fundic height: __________
Vital signs: BP= _______ HR= ______ RR= ________ tenderness: _______ (occasional/mild) uterine contractions:
Temp. _______ Page 5 ________ fetal movement ______________
Age of Gestation: _______________
bowel sounds:
Labor no. per minute
1.Abdominal Status: FU: _____ EFW: ________ AOG: _________
a) Presence of uterine contraction:
frequency duration interval intensity *Leopold’s Maneuver:findings: describe:
LM I: __________________________________________
_______________________________________________
b) IE Result: _______________________________________________
LM II: __________________________________________
time Dilat’n Efface’t BOW station discharges Done By _______________________________________________
Cond. _______________________________________________
LM III: _________________________________________
_______________________________________________
_______________________________________________
Past Medical History
LM IV: _________________________________________
a.) Includes childhood illnesses (mumps, measles, german
_______________________________________________
measles, poliomyelitis, etc) ________________________
_______________________________________________
__________________________________________________
__________________________________________________
e.) Genitourinary tract:
(Darkly pigmented) inguinal region: _________________
b) Any previous health care contacts- Include diagnostic test
vaginal secretions (watery or bloody): _______________
results and date : u/a, cbc, bld. Typing, glucose screening
presence of haemorrhoids: ________________________
test, utz result: ______________________________________
f.) Extremities: symmetrical length: _____________________
___________________________________________________
size upper and lower extremities: ___________________
c) Allergy- include food and drug hypersensitivity___________
edema: _______ varicosity: _____ limitation of ROM____
___________________________________________________
swelling of joints: ______ peripheral pulses: __________
d) Use of OTC/prescribed drugs __________________________
tenderness: ______ claudication: ___________________
___________________________________________________
g.) Integumentary: gravidarum striae-: ____________________
e) Past pregnancies:
specify location: ______ lesions: ______ rashes: ______
No. Of Yr Method Place of Birth Cond’n Condn of hematoma/petechiae: _____ chloasma: ______________
Preg. of Del. del./attended by wt baby
Post Partum
h.) Abdominal status:
Prenatal History location and size of the uterus: ______________________
d1) General physical and emotional state of the mother during condition of the uterus: ____________________________
pregnancy ________________________________________ i.)GUT status:presence of vaginal discharge: __________
__________________________________________________ amount: ____________ color: _______________________
d2) Prenatal check up/consultations: condition of the perineum ( particularly if episiotomy is
1st trimester (frequency):___________________________ done):____________________________________________
Diagnostic & result: _____________________________ functioning of the bladder (time and amount of first urine, time
2nd trimester: _____________________________________ of first BM postpartum)_________________________
Diagnostic & result: _____________________________ _________________________________________________
3rd trimester: _____________________________________ j.) Emotional/ Psychological Status
Diagnostic & result: _____________________________ postpartum blues: ________ depression: _____________
d3) Pregnancy complications & discomforts during present heightened emotional reactions/labile moods: _________
pregnancy(if any)- nausea and vomiting: _______________ _________________________________________________
loss of appetite: ______ edema: ________ UTI : ________
co morbid illness: ______ Vag’l bleeding: ____________ Menopause: _____ onset: ____________
abnormal weight change: ______ HPN: _______ Hysterectomy/ Oophorectomy: ____________________________
d4) Was pregnancy planned: Yes: ______ No: ______ Problem with: Vaginal lubrication: _____ hot flushes: ________
when was quickening felt: __________________________ Vaginal discharge: ______ others: ________________________
attitude of father: __________________________________ Hormonal therapies: ___________________________________
place where mother plans to give birth: _______________ Osteoporosis medications: ______________________________
_________________________________________________ Practices BSE: ____ Last mammogram: ____________________
Gynecologic History: Last Pap smear: _________ Results: _______________________
a.) Surgery affecting the: breast: _____ Mastectomy: _______ Objective (Exhibits)
hysterectomy: _____ Hysterectomy: ______ TAHBSO : Genitalia (warts/ lesions): _______
b.) Ectopic pregnancy: _______ STI test results: _________________________________________
c.) Reproductive tract diseases: PID: ______ vaginal bleeding/ discharge: ________
Polycystic ovarian disease: ______ H-mole : _____ Management: Meds: prescribed:___________________________
Others: specify: __________________________________ _______________________________________________________
d.)Breast:(symmetrical): ______ size and shape ______ Nursing Diagnosis: ______________________________________
retractions/ dimpling: ______ nipple discharge: _______ _______________________________________________________
redness of the skin: _____ visible superficial veins_____ lumps _______________________________________________________
_______________________________________________________
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Which family member makes healthcare decisions/ is spokesperson
for client: _________________________________
Presence of Advanced directives: _______ Code status: _______
MALE: Subjective (Reports) Durable medical power of attorney: ___________
Circumcised: ________ Page 6 Designee: ____________________________________________
Practices self examination: Breast: _________ Health goals: ___________________________________________
testicles: ________ Current health problem: client understanding of problem:
Prostate disorder: _________ ________________________________________________________
last prostocopic/ prostate exam: ____________ ______________________________________________________
last PSA date: ______________ Special health concerns (e.g. impact of religious/ cultural practices):
Medications/ herbals: ____________________________________ _____________________________________________
Objective (Exhibits) _______________________________________________________
Genitalia: Penis (circumcised): _______ warts/ lesions: ______
bleeding/ discharge: _______ Familial risk factors (indicate relationship):
Testicles (e.g. lumps): ________ Breast examination: ________ Diabetes: _____________ Thyroid (specify): ____________
STI test results: _________________________________________ Tuberculosis: ____________ Heart disease: __________
_______________________________________________________ Stroke: __________________ Hypertension: ____________
Nursing Diagnosis: ______________________________________ Cancer: ________________ Kidney disease: ____________
_______________________________________________________ Epilepsy/ seizures: ________
_______________________________________________________ Mental illness/ depression: ___________
others: _______________________________________________
SOCIAL INTERACTIONS Vitamins: _________________ Herbals: ____________________
Subjective (Reports) Street drugs: _________
Relationship status: Single: _____ Married: _______ Alcohol (amount/ frequency): ______________ Tobacco: ______
Separated/ Annulled/ Divorced: ________ Widowed: ______ Smokeless tobacco: ______
Living with (Specify): ____________________________________ Expectations of this hospitalization:
Yrs of Relationship:__________ _______________________________________________________
Perception of relationship: _______________________________ Will admission cause any lifestyle changes (describe):
Concerns/ stresses: _____________________________________ _______________________________________________________
Role within family structure: ______________________________ _______________________________________________________
Number/ Age of children: __________________ _______________________________________________________
Perception of relationship with family members: _____________ Evidence of failure to improve: ____________________________
_______________________________________________________ _______________________________________________________
Extended family: ________________________________________ Date of last physical exam: _______________________________
other support persons: __________________________________ Nursing Diagnosis: _____________________________________
Ethnic/ Cultural affiliations: _______________________________ _______________________________________________________
Strength of ethnic identity: _______________________________ _______________________________________________________
Feelings of (describe):
Mistrust: _____________________________________________ DISCHARGE PLAN CONSIDERATIONS
Rejection: ____________________________________________ Projected length of stay: ___________________ Anticipated date of
Unhappiness: _________________________________________ discharge:_______________
Loneliness/ Isolation: __________________________________ Date information obtained: ___________
Problems related to illness/ condition: ______________________ Resources available
Problems with communication (e.g. speech, another language, brain Persons: _____________________________________________
injury): ___________________________________________ financial: _____________________________________________
Use of speech/ communication (list)_______________________ Community support: ___________________________________
____________________________________________________ Groups: ______________________________________________
Is interpreter needed:Yes ______ No ______ Areas that may require alteration/ assistance:
Primary language: _________________________ Food preparation: _________________
Objective (Exhibits) Shopping: _______________________
Communication/ speech: Clear: ______ Slurred: _______ Transportation: ___________________
Unintelligible: _____ Aphasic: ______ Ambulation: ______________________
Unusual speech pattern/ impairment: _____ Medication/ IV therapy: _____________
Laryngectomy present: _____ Treatments: ______________________
Family interaction (behavioural pattern)_____________________ Wound care: ______________________
_______________________________________________________ Supplies: _________________________
Nursing Diagnosis: _____________________________________ Homemaker/ maintenance (specify):
________________________________________________________ _______________________________________________________
______________________________________________________ Physical layout of home (specify):
_______________________________________________________
TEACHING/ LEARNING Referrals (date/ source/ services)
Subjective (Reports) Social services: _______________________________________
Communication Dominant Language (specify): Rehab services: _______________________________________
_______________________________________________________ Dietary: ______________________________________________
Second language: _______________________________________ Home care: ___________________________________________
Literate (reading/ writing): ______________ Respiratory/ O2: _______________________________________
Educational level: _____________________________________ Equipment: ___________________________________________
Learning disabilities (specify): ___________________________ Supplies: _____________________________________________
Cognitive limitations: ____________________________________ Other: _______________________________________________
Ethnic Affiliation: __________________________
Health and illness beliefs/practices/ customs: _______________
_______________________________________________________
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