POSTPARTUM: ASSESSMENT GUIDE IDENTIFYING DATA Date__________ PP Day__________ Marital Status__________ Weeks Gest.__________ Name_____________________________ Age__________ Ethnic Group__________ Address__________________________ Religion______________ Education/Occupation: Wife_____________________ Husband_____________________ Gravida_____ Para_____ Abortions_____ Living Children & Ages__________________ PRENATAL: Preparation___________ Medications_________________________________________ Blood Type____________ Rh__________ Serology__________________ Significant Family, Personal, OB History, Complications_____________________________ ____________________________________________________________________________________ LABOR: Membranes Ruptured: Artificially_____ Spontaneously_____ Time_____ Appearance________ Stimulation (type)____________ Meds.____________ Anesth.____________ Length of Labor: Stage I__________ Stage II__________ Stage III__________ Fetal Distress___________________________ Complications___________________________ DELIVERY: Date/Time____________ Type____________ Presentation____________ Episiotomy/Incision________________ Adm. Hct.__________ PP Hct.__________ Infant: Apgar (1)____________ (5)____________ Complications____________________________ Wt.__________ Sex__________ Method of Feeding_____________________________ Newborn Nursery______________ Neonatal Intensive Care Unit______________ POSTPARTUM: ASSESSMENT GUIDE (continued) IDENTIFYING DATA (Continued) POST PARTUM: Meds.______________________________________________ Allergies_____________________ **Description of: Baseline 1st Day 2nd Day Vital Signs ________________ _______________ ________________ Breasts/Nipples ________________ _______________ ________________ Incision (BTL-C/S) ________________ _______________ ________________ Fundus/Bladder ________________ _______________ ________________ Episiotomy/Hemorrhoids ________________ _______________ ________________ Lochia ________________ _______________ ________________ Pretibial Areas/Calves ________________ _______________ ________________ **Note any abnormalities. OXYGENATION: V/S - B/P, PULSE, RESPIRATION Faintness or "Lightheadedness" since Delivery_____________________________________ Breathing Problems since Delivery_________________________________________________ Smoking (amount/day)__________________________________ NUTRITION Typical Diet at Home: Breakfast_______________________________________________________________________ Lunch___________________________________________________________________________ Dinner__________________________________________________________________________ Snacks__________________________________________________________________________ Appetite in Hospital______________________________________________________________ Fluid Intake Per Day (cc's)_______________________________________________________ ELIMINATION Urinary: Time and Amount of 1st PP Voiding_______________________________________________ Subsequent Frequency and Amount of Voidings_____________________________________ Bowel Movement Since Delivery__________________________________________________ POSTPARTUM: ASSESSMENT GUIDE (continued) ACTIVITY Ability to Ambulate_______________________________________________________________ Sleep and Rest Patterns___________________________________________________________ SAFETY AND SECURITY Appearance on First Sight_________________________________________________________ Feelings about Labor and Delivery_________________________________________________ Main Focus of Attention___________________________________________________________ Discomfort Experienced since Delivery (episiotomy, headache, afterpain) __________________________________________________________________________________ Degree of Dependency/Independency in Caring for Self______________________________ Knowledge of Self Care (breasts, episiotomy)_______________________________________ SEXUALITY Pregnancy Planned_________________________________________________________________ Contraception Plans_______________________________________________________________ LOVE AND BELONGING Thoughts About How Baby is Progressing __________________________________________________________________________________ Mother's Knowledge of Baby Care (safety, feeding, bathing) __________________________________________________________________________________ Concerns About Taking Baby Home___________________________________________________ Help at Home______________________________________________________________________ Family Reaction to Birth (siblings, father, grandparents __________________________________________________________________________________ SELF-ESTEEM Reactions to and Communication with Infant (body contact, security) __________________________________________________________________________________ Infant's Reaction to Mother_______________________________________________________ Role Fulfillment Vs. Conflict_____________________________________________________ SELF-ACTUALIZATION Future Plans for Self______________________________________________________________ Include Erikson's Stage of Growth and Development __________________________________________________________________________________ NEWBORN PHYSICAL ASSESSMENT GUIDE am Date of birth __________________ Time pm Gestational age_______ Mother's blood type ____________ Coombs_______ Infant's blood type ____________ Coombs_______ Delivered by ___________________ Type of del. _____________ Apgar ___1 min. ___5 min. Weight ___________ gm. Length ___________ cm. Head circum. ______ cm. ___________ lbs. ___________ in. Chest circum. ______ cm. OXYGENATION Temperature ___________ Heart rate ________ Respirations _________ Rhythm ________ Rhythm _________ Neck Motion __________ Tenderness or Nodes __________ Breast Engorgement __________ Nipple size __________ Breast tissue __________ Chest Resp. Movem. __________ Breath sounds __________ Rales __________ Rhonchi __________ Wheezes __________ Ribs __________ Clavicles __________ Patent airway __________ Retractions __________ Apnea __________ Chin lag __________ See-saw pat. __________ Signs of RDS: Secretions: Flaring __________ Viscus __________ Grunting __________ Amount __________ Color __________ NUTRITION Formula/Breast __________ General Appearance: Nutrition __________ Musc. flexion __________ Movement __________ Abdomen Visibility of Vessels __________ Bowel sounds __________ Hernias __________ Umbilicus: Whartons Staining __________ # vessels __________ jelly __________ NEWBORN PHYSICAL ASSESSMENT GUIDE (continued) ELIMINATION Genitalia Engorgement __________ Immaturity ___________ Voiding ___________ Meconium __________ Females: Labia _________ Clitoris _________ Vagina ________ Urethra ________ Males: Testes _________ Scrotum/Rugae _________ Ext. Meatus _________ Rectum Patency _________ Dimples ____________ Sinuses ___________ MOBILITY Extremities ROM of all joints: Neck _________ Shoulder _________ Elbow ________ Wrist ________ Hips _________ Knee _________ Ankle ________ Spontaneous motor activity __________________________ Extremities Polydactyly __________ Syndactyly __________ Fractures __________ Reflexes Moro __________ Babinski __________ Sucking __________ Stepping __________ Rooting __________ Grasping: Palmar __________ Plantar __________ pHisoDerm bath @ __________________ Temp. after bath __________ Color__________ LOVE AND BELONGING Interaction with parents _______________________________________________________________________________________ _______________________________________________________________________________________ NEWBORN PHYSICAL ASSESSMENT GUIDE (continued) SAFETY AND SECURITY Skin Milia _________ Cyanosis _________ Pallor _________ Jaundice _________ Vernix _________ Lanugo _________ Mec. stain _________ Erythema T. _________ Mongolian spots_________ Simian creases_________ Telangiectatic nevi_________ Hemm. sites: a. petechiae_________ b. ecchymosis________ Head Sutures _________ Fontanels _________ Molding _________ Caput. Suc. _________ Cephalhem. _________ Hair _________ Face Symmetry _________ Eyes Movement _________ Iris _________ Pupil _________ Lid _________ Conj. _________ Sclera _________ Ears Position _________ Cartilage _________ Recoil _________ Canal _________ Ear tags _________ Nose Patency _________ Discharge _________ Mouth Lips _________ Teeth _________ Gums _________ Palate _________ Lesions _________ Tongue _________ 6/09 postpartum & newborn assessment guide