Postpartum Assessment Guide — DeAnza College Student: Client Initials:

Respiratory (Air): Date: Room:

 cough  dyspnea
 rales  wheezes Diet: Nurse:
 rhonchi
color: Allergies:
Cardiovascular (Water): lochia: /°; color: ; odor:  clots Cultural Background:
 breast engorgement  Homan's Sign
 orthostatic hypot'n  disphoresis Primary Language:
 petechiea  hematomas
 edema  hemorrhoids Date & Time of Birth:
 vertigo
Childbirth Prep?
GI (Food/Elim/Hazards): appetite/intake: Hct: Hgb: Blood Type:
 bowel sounds x___  n/v
 abd distention  constipation abd tone: T P A L Rhogam:  Needed  Given
 diarrhea  flatus  Vaginal  Cesarean Rubella:  Imm  Non-imm
 hemorrhoids
 last stool _______________________ Feed:  Breast  Bottle HBSAg:  Pos  Neg

GU (Elim/Hazards): voiding pattern: Med Order Last Given

 with assist?
 bladder distention  urine retention
 oliguria  dysuria

 foley: ____ Fr; @ _____ mL ________

IV: @ cc/°; ↑ ;Δ ;↓
MS (Activity/Normalcy): fundal location: ; consistency:
 uterine cramping  diastasus rectus
 abdominal striae  perineal muscles mobility:

1500–1600:  charts; assess

Integument (Hazards/Normalcy): pigmentation: (nipples, linea negra, striae, chloasma)
breasts:  soft  firm 1600–1700: chart vs;
nipples:  dry  intact
perineal:  swelling  bruising 1700–1800:
_____°  laceration  episiotomy REEDA
1800–1900:
CNS (Social Interaction/Hazards): affect:
 LOC_______________  tremors 1900–2000:
 pain_______________  clonus
 epidural @ _________  DTR's 2000–2100:
2100–2130: final charting;
Health Deviation:
 postpartum  pumping
 infant security teaching Input: Vitals

Developmental / Emotional: bonding: Temp

breastfeeding consult?  need  recv'd HR
 neo. care (ch. 19)  inquisitive? social support:
Output: RR
Pain
Sex: Apgar 1m: 5m: Blood Type: Wt. Len. Dir. Coombs: BP