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Cheat Sheet
Postpartum Assessment Sheet...
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_____________ Patient Initials: _____________
Newborn Assessment BP: ________ T ______ P______ R____ BP: ________ T ______ P______ R____ Heart : Regular irregular Tachycardic Bradycardic (normal 110-160) Respi : Labored regular unlabored tachyneic dyspneic (normal 30-60cpm) With O2 inhalation ? Yes No _____LPM via _______ NGT ? _____________ Lung sound : clear diminished crackles wheeze Bowel Sounds:_______ Head (fontanel):____________ Ears:_______________ Eyes:__________ Mouth:_______ Chest :________ :________ Skin color :_________ :_________ patho phys jaundice Umbilicus (cord) : clamped unclamped dry intact wet odor drainage_______ Circumcised ? Yes No describe: _________________ _______________ ______
Room #: _______
DOB: ________ Age: ____ Status: ____ Religion: _________ Height: ________ __________ __ Weight: ________ Blood Type: ______ Allergies: ____________________________________________ Diet: ______________ Activity: ______________________________ Restriction/precaution:_____________________________________ Admission Date: ______________ AP/0B: _______________ PED: ____________ NB: ______________ Reason for Admission: _____________________________________ __________________ ________ ___________________ __________________ __________________ ___________________ ___________ _ __________________ ________ ___________________ __________________ __________________ ___________________ ___________ _ Health History: History : __________________ ________ ___________________ __________________ __________________ ___________________ ___________ _ __________________ ________ ___________________ __________________ __________________ ___________________ ___________ _ Maternal Data G __ P__ ( AB __ Pt __ T __ L __ ) Obstetrical History: GDM PIH PI H Hypotension Clotting problems __________________ ___________________________ __________________ __________________ ___________________ ___________ _ __________________ ___________________________ __________________ __________________ ___________________ ___________ _ Complications during pregnancy? Yes No What: _______________ Complications during labor? Yes No What: _______________ _ Induction of Labor? Yes or No Medicine Used: _________________ Delivery Date: Date: ___________ ___________ Time: _____ _____ AOG:____ Gender:_____ Gender:_____ CS type: ________________ NSVD (Epis,lac (Epis,lacera) era) ________________ NB: Voided: ____ Stool: ___ Apgar 1___ 5____ H’t:______ W’t: ____ Feeding: ____________ With anesthesia? Yes No Type used: _______ _______________ ___ EBL: _______ Additional Surgery:_____________________________ Assessment Maternal time__:__ BP: ________ T ______ P______ R____ O2 Sat: ___ BP: ________ T ______ P______ R____ O2 Sat: ___ Heart : Regular irregular Tachycardic Bradycardic Resp: Labored regular unlabored tachyneic dyspneic With O2 inhalation ? Yes No _____LPM via _________________ ___ Lung sound : clear diminished crackles wheeze Cough: present productive non productive Breast : Soft Filling Engorged other:____________ ______________ Nipple : norm flat evert invert flat sore cracked other: _________ Abdomen: firm tense distended tender Bowel sounds : normoactive hypo hyper absent BM:____ Flatus?____ Fundus : firm massaged to firm bog gy Location:________________ What used for incision closure? Staples steri strips glue ___________ Dressing: dry intact removed wet describe:___________________ other:_____________________ __________________ ______________ Incision: R E E D A other:___ How many times changed pads? __ Scant Moderate Heavy ________ ________ Done with first 2 voids? Yes No Amount/ Charac: _______________ Catheter Amount/ Charac: _____________ _______________ _____ Varicosities? Yes No Loca/ descrptn:_______ _______________ _____ Edema? Yes No Loca/descrptn: _______________________________ DTR: absent 1+sluggish,dull 2+active/normal 3+brisk 4+briskw/clonus Clonus ? Yes No Homan’s sign: Yes No Anus:______________ Anus:____________________ ______
Labs Test Hgb/ Hct ABO Rh Hep B Rubella GBS RPR/VDRL PPD Blood other
Date Taken: Patient Value
Normal Range
Significance
Labs Test Rh RPR Coombs Hgb/Hct others
3hr
Normal Range
NURSING ACTIONS Time
Assessment
Medications Ordered date Name
Intervention
Freq/dosage/ route
Ordered date Name
Freq/dosage/ route
Newborn’s I&O
Time
1hr
Date Taken: Patient Value
Void
Stool
Feeding
Amount
L (time)
R (time)
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