Antepartal Assessment

8/13/2019 Antepartal Assessment

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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.


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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. #dult Illness(circle)


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?. %ancer! type! location

@. *ematolo$ic 4 leedin$ disorders! anemia! sic le cell! hemophilia

A. "eurolo$ical 4 epilepsy (seizures)! muscular dystrophy

. ,sychiatric disorders 4 descri e

C. Dia etes 4 a$e of onset__insulin dependent E " *ypo$lycemic E "

. #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


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F. outh and throat

8. "ec

*. 0ymphatic

I. Breasts

. 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


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;. "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


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client eat 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 route other &stimated amount used daily

F. ,ersonal hy$iene pattern

8. Dental hy$iene

# 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$___________________________________________________


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"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 lems

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

Is the pre$nancy planned or unplanned

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

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

#ccepts the fact of her pre$nancy incorporates the fetus into her ody ima$e! identifies the fetus as aseparate 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.


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,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(* $(l healer! (rreli"i( ! &er!(nnel#

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Antepartal Assessment