SOUTH COLLEGE DEPARTMENT OF NURSING NUR 125 Maternal- Child N r!

in" ANTEPARTAL ASSESSMENT Student___________________________________Date_____________

Brief Summary: (Reason for current hospitalization):

Fill out each area. If date is not availa le! put Date "ot #vaila le and $ive reasons. I# Identi$%in" Data #. %lient initials________ #$e_________ &thnic 'ri$in_______________________

%hart (______________ )arital Status____________ Reli$ion_______________

II# General A&&earan'e *ei$ht______________ %urrent +ei$ht__________ ,re-pre$nant +ei$ht__________ Si$nificance of +ei$ht for $estational +ee.s (circle) /"0! a ove "0! elo+ "0____ %urrent vital si$ns includin$ F*R 1 0ocation________________________________ 2ital si$ns pattern (ran$e)__________________________________________________________________

III# Pattern! ($ Health Care #. 3ype of health facilities used 4 circle: physician5s office! *ealth Department %linic! &mer$ency Room! /I% pro$ram! other.

B. 6se of preventive health service 4 circle: %linic! &mer$ency Room! chest 7-ray! annual physician e7am! self reast e7am! previous antepartal care. Screenin$ services for: Indirect %oom s! hypertension! dia etes! ,ap test! tu erculosis! street dru$ use! S3D! *I2! *epatitis B! other Descri e if appropriate:

I)# Parit% C rrent 8ravida_____,ara_____93_____,_____#_____0_____:0"),_____ &D% y "a$ele5s rule___________________ &D% y sono$ram____________ ;uic.enin$ date____________multiparity__________________________________ %urrent $estational +ee.s______Fundal hei$ht________correlation: yes<no_______ )# Pa!t Hi!t(r% =. Description of $eneral health prior to pre$nancy

B. ,revious health pro lems =. Specify any childhood illness or immunizations (circle) mumps +hoopin$ cou$h rheumatic fever measles scarlet fever seizures ru ella polio diphtheria urinary tract infection chic.en po7 other

>. #dult Illness(circle)

dia etes cardiac disease urinary tract infection cancer respiratory disease seizures hypertension anemia tu erculosis %.2.#. hepatitis se7ual transmitted disease (S.3.D.) /hen appropriate! put date dia$nosed and treated. ?. Recent e7posure to any infectious diseases.

?.

,revious hospitalization or operations! lood transfusions! dia$nostic procedures

D. #ller$ies or adverse reactions to medications! foods or contact a$ents

)I# Fa*il% Medi'al Hi!t(r%

=.

Descri e health status of father of a y.

B. Familial disease or traits 4 record appropriate items from the follo+in$ list. %ircle +here appropriate and identify +hich family mem er has any of the listed pro lems. =. %ardiovascular 4 heart disease! %2#! hypertension >. )aternal history of ,I*

?. %ancer! type! location @. *ematolo$ic 4 leedin$ disorders! anemia! sic.le cell! hemophilia A. "eurolo$ical 4 epilepsy (seizures)! muscular dystrophy B. ,sychiatric disorders 4 descri e C. Dia etes 4 a$e of onset__insulin dependentD E " *ypo$lycemic E " F. #rthritis G. Renal disease =H. #ller$ies 4 descri e ==. 3u erculosis =>. %on$enital anomalies =?. )ultiple ,re$nancies (t+ins! triplets! etc.) )II# Re+ie, ($ S%!te*! - Hi!t(r% . Ph%!i'al E/a*

If client has pro lems complicatin$ her pre$nancy! descri e under the appropriate system.

#. Inte$ument 4 si$nificant chan$es

B. *ead 4 headache! faintin$! dizziness! other

%. &yes 4 lurrin$! spots! flashes of li$ht! other D. &ars

&. "ose and sinuses

F. )outh and throat

8. "ec.

*. 0ymphatic

I. Breasts

I. Respiratory J. %ardiovascular 4 chest pain! edema of face of e7tremities! hypotension! hypertension! murmurs! throm ophle itis! other

0. 8astrointestinal 4 indi$estion! nausea! vomitin$! anore7ia! epi$astric pain! constipation! hemorrhoids! other

). 8enitourinary 4 freKuency! nocturia! dysuria! hematuria! other ". )usculos.eletal 4 descri e discomforts in ac.! le$s! a domen if present.

Descri e pelvic measurement as adeKuate or inadeKuate for va$inal delivery +ith e7planation if availa le.

'. &ndocrine

,. *ematopoietic 4 anemia! sic.le cell results! Rh of #B' incompati ility +ith previous pre$nancies! other

;. "eurolo$ic 4 dizziness! faintin$! Ltin$lin$ sensationsM! other

R. Reproductive 4 a$e at menarche____! usual va$inal leedin$! va$inal dischar$e! perineal itchin$ or urnin$! irth control methods previously used and date last used.

S. Se7uality 4 any concerns<pro lems<needs to discuss.

,revious pre$nancy history: ,lease dra+ a rou$h $rid ac. of this pa$e as needed.

Delivery Date

0en$th of ,re$nancy! %omplications

3ype of Delivery! %omplications! Intrapartum! ,ost-,artum

Se7 of Infant

/ei$ht of Infant

Infant %ondition at Birth

%urrent *ealth of Infant

)III# La0 Data1 U!e la0 !heet I2# Per!(nal Pr($ile

#. "utritional assessment: food preferencesN ho+ much starch or clay (,ica) does

client eatD Descri e appetite status 8 F ,! *yperemesis. Special diet: dia etic! ve$etarian! mostly fast foods! +ei$ht reduction! ,J6

B. &limination pattern 4 constipation! hemorrhoids! diarrhea #ides uses: %. Sleep ,attern 4 descri e any pro lems if present

D. &7ercise

&. *a its: alcohol! to acco! caffeine! street dru$s 1 routeD other &stimated amount used daily

F. ,ersonal hy$iene pattern

8. Dental hy$iene

2# Intera'ti(n ($ P!%'h(l("i'al3 S('i(l("i'al and Phil(!(&hi'al Reli$ious preference *i$hest $rade completed in school %hild irth education classes E&S "' "um er of people in client5s household *ead of household 'ccupation of %lient________________________________________ 'ccupation of Si$nificant 'ther________________________________ &ducation__________________________________________________ *ousin$___________________________________________________

"ei$h ors__________________________________________________ Si"ni$i'ant (ther4! rea'ti(n and $eelin"! a0( t &re"nan'%

Client4! rea'ti(n and $eelin"! a0( t &re"nan'%

/ho do you $o to +hen you have pro lemsD

*o+ do you feel a out this ne+ life you are rin$in$ into the +orldD

Is the pre$nancy planned or unplannedD

*as anyone told you anythin$ a out pre$nancy that +orries youD

Stat ! ($ 'lient4! de+el(&*ental ta!5! in relati(n t( !tate ($ &re"nan'%# 6nderline appropriate developmental tas..

#ccepts the fact of her pre$nancy incorporates the fetus into her ody ima$e! identifies the fetus as a separate entity! ready to $ive up pre$nancy and assume careta.er-maternal role. &7plain

Descri e if client has made no pro$ress +ith developmental tas.s of pre$nancy.

,lans for livin$ arran$ements and facilities for infant care C lt ral '(n!iderati(n! ! 'h a! !&e'ial 'ere*(nie!3 $((d!3 'l(thin" (r +i!itati(n $r(* $(l5 healer! (r reli"i( ! &er!(nnel#