Obstetric Assessment Tool

XAVIER UNIVERSITY
ATENEO DE CAGAYAN Upon Assessment:

NCM 109 RLE Vital Signs: HR:______ RR:______ BP:______ Temp:______ Actual Date of Delivery:________________ Time:_________
OBSTETRIC ASSESSMENT TOOL O2Sat:____ Ht.:______ Wt.:______ BMI:_____ Type of Delivery:___________________________________
Interpretation of BMI:______________________________ If C/S, Indication:___________________________________
Name:_________________________________ Block:_____ III. Past Obstetric/Medical/Surgical History Position of Fetus:___________________________________
Are of Exposure:_______________________ CI:__________ Complications during Labor:__________________________
Illness Date
I. GENERAL INFORMATION Onset and Duration of Labor:_________________________
Name:___________________________________ Age:_____ Episiotomy:________ Lochia:_________ Amount:_________
Birthday:______________________ Civil Status:__________ Complications of Pregnancy:__________________________
Sex:_____ Religion:__________ Occupation:_____________ Excessive bleeding:___________________________
Income:__________ Address:_________________________ Infections:__________________________________
_________________________________________________ Infant’s AGPAR Score:_______________________________
Informant:_______________ Relation:__________________ Plans for feeding:___________________________________
Admission Date:_____________________ Time:__________ IV: History of Family Illnesses (Check what applies) _________________________________________________
Chief Complaint:____________________________________ ___ Hypertension
Attending ___ Coronary Artery Disease (CAD) VI. Gynecologic History
Physician:_________________________________ ___ Cerebro-vascular Disease (CVD) Age of Menarche:___________________________________
Diagnosis/Impression:_______________________________ ___ DIabetes Mellitus Menstrual Cycle:
II. History of Present Illness: ___ Kidney Disease Interval/Length of Cycle: _____ days
__________________________________________________ ___ Tuberculosis Duration of Menstrual Flow: _____ days
__________________________________________________ ___ Cancer Amount of Menstrual Flow: __________
__________________________________________________ Others (Specify):____________________________________ Menstrual Discomfort:_______________________________
__________________________________________________ Vaginal Discharge (odor,color):________________________
_____________________________________________ V. Obstetric History (Pregnancy, Labor, and Birth) Bleeding between periods:___________________________
Current Medications (include Dosage, Timing, Route, and Para:_____ Gravida:_____ TPAL:_______________________ Sexually Active:___ Sexual
Indication of use) : Prenatal Care concerns/difficulties:__________
Coverage:______________________________ Recent change in frequency/interest:___________________
Name, dose, timing, route. Indication Place of Prenatal Care:_______________________________ Reproductive Tract
Total number of visits:_______________________________ Surgery:___________________________
Any abnormal findings:______________________________ Reproductive Family Planning Methods Used:____________
Pre-pregnancy Weight:______________________________ For how long:______________________________________
Weight Gain:_______________________________________ Side Effects if any:__________________________________
Last Menstrual Period:_______________________________ Previous Miscarriages/Abortions:______________________
EDC:______________________________________________
Age of Gestation:___________________________________
VII. Assessment of Systems
Objective
General Appearance and Mental Status:________________ Eyes/Ears
Personal Hygiene/Habits:____________________________ Objective Breasts
Hair:_____________________________________________ Edema in eyelids:___________________________________ Objective/Subjective
Clothing/Manner of Dress:___________________________ Sclera and Conjunctiva:______________________________ Breasts Changes (Areola):____________________________
Body Odor:________________________________________ Spots before the eyes:_______________________________ Breast Size:________________________________________
Skin Diplopia (Double Vision):_____________________________ Presence of Colostrum:______________________________
Integrity/Turgor:________________________________ Subjective Adequacy for Breast for Breastfeeding:_________________
Speech: _____Clear _____Slurred Vision Problem: R________________ L_________________ Abnormal Signs:____________________________________
_____Unintelligible _____Aphasic Last Examination:___________________________________ PerfoRm BSE (frequency and schedule):_________________
Subjective Ears (Hearing Loss/Deficiency):________________________
Pain (Precipitating):_________________________________ Last Examination:___________________________________ Abdomen
Quality of Pain:_____________________________________ Objective (Antepartum)
Location:___________________ Severity:_______________ Nose Fundal Height:_____________________________________
Time (Onset, Frequency, Duration): Nasal Congestion:___________________________________ Leopold’s Maneuver:________________________________
_________________________________________________ Sense of Smell:_____________________________________ Fetal Position:______________________________________
Others/Comments:_________________________________ Epistaxis:__________________________________________ Pelvic Measurement:________________________________
Others/Comments:_________________________________
Head and Scalp Circulation
Symmetry:________________________________________ Mouth, Teeth, and Throat Ankle/Leg Edema:__________________________________
Countout:_______________ Distribution:_______________ Objective History of Hypertension:_____________________________
Thickness:________________ Excessive:________________ Condition of Mouth:_________________________________ Extremities: Numbness___________ Tingling____________
Dryness/Oiliness:__________ Use of Hair Dye:___________ Condition of Teeth and Gums:_________________________ Change in Frequency/Amount of Urine:_________________
Lesions:___________________________________________ Appearance of Tongue:______________________________ Hooman’s Sign:_____________________________________
Gingival gum hypertrophy:__________ Lesions:__________ Others/Comments:_________________________________
Subjective Dental Hygiene:____________ Dental Carries:___________
Headache Severity:_________________________________ Objective
Location:__________________________________________ Neck/Lymph Nodes BP: (R) Lying______________ Sitting______________
Frequency:________________________________________ Objective BP: (L) Lying______________ Sitting______________
Fainting Thyroid Heart Sounds: Rate_____________
Spells/Frequency:____________________________ Hypertrophy:________________________________ Rhythm______________
Tingling/Numbness/Weakness (Location): Palpable Lymph Nodes:______________________________ Pulse: Carotid_____ Radial_____ Popliteal_____
_________________________________________________ Temporal_____ Femoral_____ Dorsalis Pedis_____
Others/Comments:_________________________________ Capillary Refill:_________________ Color:_______________
Changes in Limitations Imposed by Conditions:____________________
Weight:__________________________________ Sleep
Diuretic Use:_______________________________________ Number of Hours:_______________ Naps:______________
Sleeping Aids:______________________________________
Cyanosis/Pallor:____________________________________ Objective Difficulty in Sleeping:________________________________
Varicosities:_______________________________________ Current Weight:_____ Height:_____ Body Build:__________ Feeling on Awakening:_______________________________
Nail Beds:_________________________________________ Skin Others/Comments:_________________________________
Mucous Membranes:________________________________ Turgor:________________________________________
Others/Comments:_________________________________ Mucous Membranes
(Moist/Dry):______________________ Ego Integrity
Respirations Hernia/Masses:____________________________________ Subjective
Objective Other Comments:___________________________________ Report of Stress Factors:_____________________________
Respiratory Rate:_____ Depth:_______ Symmetry:_______ Ways of Handling Stress:_____________________________
Use of Accessory Muscles:________ Nasal Flaring:________ Elimination Financial Concerns:_________________________________
Abnormal Breath Sounds:____________________________ Subjective Relationship Status:_________________________________
Cyanosis:____________ Clubbing of Fingers:_____________ Usual Bowel Pattern:________________________________ Lifestyle:__________________________________________
Sputum Characteristics:______________________________ Last BM:__________________________________________ Recent Changes:____________________________________
Others/Comments:_________________________________ Recent: Feelings of Helplessness:_________ Hopelessness:________
Dyspnea related to:_________________________________ Character of Powerlessness:_____________________________________
Cough/Sputum:____________________________________ Stool___________________________________ Others/Comments:_________________________________
History: Amount_________________ Frequency_________________ Objective
Bronchitis_____ Asthma_____ Tuberculosis_____ Color____________________ Odor____________________ Emotional Status (Check those that apply):
Emphysema_____ Recurrent Pneumonia_____ History of GI Bleeding:__________ Hemorrhoids:_________ Calm_____ Anxious_____ Angry_____
Smoker:______ Pack/day:______ Number of Years:______ Constipation:______________ Laxative use:_____________ Withdrawn_____ Fearful_____ Irritable_____
Use of Respiratory Aids:___________ Oxygen:___________ Others:___________________________________________ Euphoric_____
Others/Comments:_________________________________
Usual Voiding Pattern:__________ Incontinence:_________
Food/Fluid Intake Urgency:________ Retention:________ Frequency:_______
Subjective Pain/Burning/Difficulty in Voiding:_____________________
Usual Diet (Type):__________ No. of meals daily:_________ History of Kidney/Bladder Disease:____________________
Last Meal Intake:___________ Loss of Appetite:__________ Others/Comments:_________________________________
Nausea/Vomiting:_____________ Dentures:_____________
Allergy/Food Intolerance:____________________________ Activity and Rest
Heartburn/Indigestion:______________________________ Subjective
Mastication/Swallowing Problems:____________________ Usual Activities/Hobbies:____________________________
Leisure Time Activities:______________________________
Safety __________________________________________________
Subjective’ __________________________________________________
Allergies/Sensitivity:________________________________ _______________________________________________
Reaction:__________________________________________
History of STD (Date/Type):___________________________ Body Map. (Illustrate in the body map how your patient Laboratory/Diagnostic Results (Include data and
Blood Transfusion/Number:__________ When:__________ looks e.g. tubes inserted, bruises, surgical incisions, physical interpretation in reactin to patient’s condition/)
History of Accidental Injuries:_________________________ abnormalities, affected areas. Mark with a small “x” where it
Fractures/Dislocations:______________________________ is located or draw it on the body may then label.) a. CBC (HbsAg)
Arthritis/Unstable
Joints:_____________________________
Back Problems:_____________________________________
Changes in Moles:__________ Enlarged Nodes:__________ b. U/A
UnusuaL Bleeding:__________________________________
Prosthesis:________________________________________
Social Interactions c. Fecalysis

Subjective
Marital Status:_________ Years in a
Relationship:_________
Living with:________________________________________ d. X-Ray/Sonogram
Concerns Stresses:__________________________________
Extended Family:___________________________________ Describe Affected Areas:
Other Support Person:_______________________________ __________________________________________________
Role within family structure:__________________________ __________________________________________________
Report of Problems Related to Illness/Conditions: __________________________________________________ Developmental Milestone
__________________________________________________ ______________________________________________ Describe behaviour in relation to the developmental tasks.
________________________________________________
Others/Comments:_________________________________
Age Psychosexual Psycho-social Cognitive
Teaching/Learning _____y/
Subjective o
Dominant Language (Specify):_________________________
Literate:_____________ Educational Level:______________
Health Beliefs/Practices:

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XAVIER UNIVERSITY

ATENEO DE CAGAYAN Upon Assessment:

Social Interactions c. Fecalysis

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