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    Ante Part Al

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    This document contains an antepartal nursing assessment form for a pregnant patient. It collects information about the patient's obstetric history, current pregnancy, lifestyle habits, nutritional status, vital signs, lab results, risk factors, discomforts, physician's orders and medications. Specific details gathered include marital status, number of previous pregnancies, complications, gestational age, LMP and EDD for the current pregnancy, prenatal lab values, screening results, prescribed diet and activity level. The goal is to obtain a full assessment of the patient's health and pregnancy to inform their nursing care plan.

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    Ante Part Al

    Uploaded by

    S
    45 views4 pages
    This document contains an antepartal nursing assessment form for a pregnant patient. It collects information about the patient's obstetric history, current pregnancy, lifestyle habits, nutritional status, vital signs, lab results, risk factors, discomforts, physician's orders and medications. Specific details gathered include marital status, number of previous pregnancies, complications, gestational age, LMP and EDD for the current pregnancy, prenatal lab values, screening results, prescribed diet and activity level. The goal is to obtain a full assessment of the patient's health and pregnancy to inform their nursing care plan.

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    This document contains an antepartal nursing assessment form for a pregnant patient. It collects information about the patient's obstetric history, current pregnancy, lifestyle habits, nutritional status, vital signs, lab results, risk factors, discomforts, physician's orders and medications. Specific details gathered include marital status, number of previous pregnancies, complications, gestational age, LMP and EDD for the current pregnancy, prenatal lab values, screening results, prescribed diet and activity level. The goal is to obtain a full assessment of the patient's health and pregnancy to inform their nursing care plan.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    45 views4 pages

    Ante Part Al

    Uploaded by

    S
    This document contains an antepartal nursing assessment form for a pregnant patient. It collects information about the patient's obstetric history, current pregnancy, lifestyle habits, nutritional status, vital signs, lab results, risk factors, discomforts, physician's orders and medications. Specific details gathered include marital status, number of previous pregnancies, complications, gestational age, LMP and EDD for the current pregnancy, prenatal lab values, screening results, prescribed diet and activity level. The goal is to obtain a full assessment of the patient's health and pregnancy to inform their nursing care plan.

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    © All Rights Reserved
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    THE COLLEGE OF STATEN ISLAND

    School of Health Sciences


    Department of Nursing
    Nursing 220 Family Centered Maternity Nursing

    Antepartal Nursing Assessment

    Student________________________________ Hospital/Unit__________________________________

    Instructor______________________________ Date_________________________________________

    Admitting Diagnosis (if on antepartal unit)_______________________________Gestational Age_________

    Prenatal History(Interview)

    1. Marital Status____________ Religion_________________ Languages Spoken________________

    Age______ Occupation____________________________ Educational Level________________

    2. Husband (significant other) occupation_____________________________________ Age_______

    Educational level_________________

    3. Children/ages_________________________________________________________________________

    4. Other dependents______________________________________________________________________

    5. Was this pregnancy planned?________ Method of contraception used___________________________

    6. Feelings regarding this pregnancy_________________________________________________________

    7. Expectant fathers reaction to the pregnancy_________________________________________________

    8. Cultural or religious concerns about the pregnancy____________________________________________

    9. Does the couple plan to attend childbirth classes?_____ If no, why not?____________________________

    10. Does the expectant father plan to be with the woman during Labor and Delivery?____________________

    11. How will this pregnancy and infant alter the couples plans for:

    Education_____________________________________________________________________________

    Career and employment__________________________________________________________________

    Lifestyle______________________________________________________________________________

    12. Housing arrangements___________________________________________________________________

    13. Financial Concerns______________________________________________________________________

    14. Habits: Smoking: Amount per day_________________ Duration_________________________________

    49
    15. Caffeine intake_________________ Alcohol intake_____________ Drug intake_________________

    16. Nutritional status: Food Allergies_______________________________ Pica________________________

    Typical diet at home

    Breakfast______________________________________________________________________________

    Lunch_________________________________________________________________________________

    Dinner_________________________________________________________________________________

    Snacks_________________________________________________________________________________

    Describe any teaching done regarding nutrition:

    _______________________________________________________________________________________

    _______________________________________________________________________________________

    _______________________________________________________________________________________

    _______________________________________________________________________________________

    Secondary Sources (Chart, Kardex)

    1. Vital Signs Pulse__________ Respiration__________ B/P___________ F.H.R.___________________

    2. Prepregnant weight____________ Present weight_______________

    3. Description of previous pregnancies


    Year Length Length Type of Hospital of Delivery Fetal Outcome
    of of Delivery (alive, stillbirth, problem?)
    gestation Labor

    4. Using TPAL system describe the number of pregnancies T P A L

    50
    5. Antepartal, Intrapartal, or Postpartal complications with previous pregnancies:

    ____________________________________________________________________________________

    ____________________________________________________________________________________

    ____________________________________________________________________________________

    6. Description of present pregnancy

    LMP__________ EDD__________ Gravida__________ Para____________

    7. Risk Factors 8. Discomforts of Pregnancy

    Diabetes Mellitus Psychosocial

    PIH Skin

    Multiple Gestation GI

    Hyperemesis Gravidarum GU

    Cardiac Respiratory

    Bleeding Disorders Musculoskeletal

    Other(describe Cardiovascular

    Other (describe)

    9. Laboratory Studies (identify lab values and indicate if abnormal by *)

    Urine: Urinalysis____________ Culture and Sensitivity____________

    Protein______________ Ketones______________ Glucose________________

    Blood: Blood type_________ Rh factor_____________ Hct__________ Hgb__________

    WBC___________ VDRL__________ Rubella Titer____________ Hbsag____________

    PPD______________ Chest XRay?____________ Treatment if positive____________________

    Cultures: Pap smear___________G.C. culture__________ HIV_________GBS_________HSV_______

    51
    Physicians orders

    Date Order

    Medications

    Diet

    Activity

    Treatments

    52

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