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Nursing III

By Douglas Ortiz,2014-04-26 19:48
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Nursing III

Nursing III

    Student: Client’s initials: Age:

     Gravida: Date: Living children ages: Para:

     Admitting diagnosis:

     PP Day:

    POSTPARTUM ASSESSMENT (DATA COLLECTION)

     Status: Hepatitis Rubella HIVGBSPHYSIOLOGICAL

    Blood Type: Rh: OXYGEN

    Skin warm to touch? Cough Sputum:

    Smokes packs per day: Skin Color: Normal for ethnic group ;Breath sounds: Abnormal: Pale ;Dusky ;Cyanotic ;Equipment in use: 02 Respiratory Rx Color of Nailbed: Homan’s Sign? Dyspnea: at rest on exertion Chest pain ;Fundus: Temperature: Height: Radial pulse: Apical pulse: Lochia: Amount: Blood pressure: Resps/min: Color: Faintness/lightheadedness since delivery? ;Condition of breasts/nipples: Breathing problems since delivery? ; Lab data: Adm Hct: PP Hct: Serology:

    Nausea or vomiting: FLUIDS AND ELECTROLYTES

    Skin turgor over sternum: ;Presence of edema: Tongue and lips: ;IV: Location: Amount of liquids taken since 7 AM today: _mL Solution: Medications: Lab Data: Comments:

    Typical diet at home: NUTRITION Appetite in hospital: % Meal consumed: Ordered diet: Dietary supplement: Comments: Medications: Lab data:

ELIMINATION Urinary: Bowel:

    Time of 1st PP voiding: Bowel sounds: Subsequent frequency & amount: ;;;;;;;;;;;;; BM since delivery? Foley catheter? ;;;;;;;;;;;;;;Consistency: Lab data: Lab data:

    Medications: Medications:

     MOBILITY AND ACTIVITY Lab data: Muscle strength: Handgrips equal Footpushes equal ;

    ROM: Normal; Limited Severely limited Medications:

     Ability to ambulate: Assist Independent ; Gait____________________

    OOB: Chair BRP Ad Lib

     REST, SLEEP AND PAIN c/o Fatigue: Reported quality of sleep: c/o Pain: Lab data: Location: Intensity: Medications: Duration:

SAFETY AND SECURITY

    Vision: Skin integrity:

     Able to see without glasses Needs glasses ;Intact: Hearing: Reddened: Location:

     Responds to normal voice tones ;Blanching erythema: Non-blanching erythema

     Hearing aid Deaf ;Incision/epsiotomy: Speech: Location:

     Clear Garbled Language Barrier ; Approx size in cms: Mental Status: Appearance:

     Treatment (dressings etc.) Alert Lethargic Unresponsive ;

    Hemorrhoids Environment:

     Perineal swelling Ice Sitz ;Degree of dependency/independency in caring for self: Appearance on first sight: Feelings about labor & delivery: Knowledge of self care (breasts, episiotomy): Main focus of attention: Allergies:

LOVE AND BELONGING

    Thoughts about how baby is progressing: Indicators: Cards Flowers Family pictures ;Mother’s knowledge of baby care (safety, feeding, bathing): Other: Religious affiliation: Concerns about taking baby home: Help at home: Social service consult needed: Family reaction to birth (siblings, father, grandparents):

SELF-ESTEEM

    Family role Reactions/communication with infant (body contact, security, etc):

    Occupation:

    Interest in appearance: Infant’s reaction to mother: Comments: Role fulfillment vs conflict:

SELF-ACTUALIZATION

    Client report of satisfaction with life: Pregnancy planned? Future plans for self: Contraception plans:

    Comments:

ERIKSON’S STAGE OF DEVELOPMENT

    What is the stage of development?

    Describe client’s characteristics/behaviors that place her in this stage.

Is stage appropriate for age?

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