OB/GYNE PATIENT ➤ Congenital disorders, hereditary diseases, multiple pregnancies,

diabetes, heart disease, hypertension,, mental retardation, renal

Name: disease or use of diethylstilbestrol (DES)
Address: (Note: daughters born to mothers who sustained their pregnancies
Contact Person: with DES may have uterine anomalies that increase their risk of
Religion: preterm labor or uterine hyperstimulation)
Sex:
Age: MATERNAL PSYCHOSOCIAL PROFILE
Birth Date:
Place of Birth: 1. HEALTH PERCEPTION-HEALTH MAINTENANCE PATTERN
Ethnicity: "How would you usually describe your health?"
Nationality: "Do you have any chronic illnesses?"
Race: "How would you describe your health at this time?"
Date of Admission: Review the daily health practices of the individual
Reason for Seeking Health Care: Dental care Exercise regimen
Marital Status: Food intake Fluid intake
Home Phone: Leisure activities
Work Phone: Responsibility in the family
Education: Use of the following:
Occupation: Tobacco Alcohol
Health Insurance: Salt, sugar, fat products Drugs
Source & Reliability:
Referral: Knowledge of safety practices
Advance Directives: Fire prevention Water safety
Room Number: Children/infants Poison
Attending Physician: control Automobile
Admitting/Final Diagnosis: bicycle

REASONS FOR SEEKING CARE Knowledge of Infant Care

Current Health Status (Narrative): Nutrition (bottle, breast-feeding)

Clothing needs
 Onset of labor, activity performed prior to onset of labor, Hygiene needs
appearance of pink (bloody show), measures performed Sleep needs
to relieve pain and support systems available during Developmental needs
labor.
 Characteristics of uterine contraction (duration, interval,
frequency, intensity) Other symptoms associated with
labor
Note: perform symptom analysis for non-pregnant client
2. NUTRITIONAL-METABOLIC PATTERN
✓ Present Obstetric History (pregnant) "What is the usual daily food intake (meals,
Gravity, Parity snacks)?" "What is the usual fluid intake (type,
Obstetric history may be summarized by a series of 4 digits using amount)?" "How is your appetite?"
the abbreviation TPAL or by a series of 6 digits using the Indigestion Nausea
abbreviation GTPALM. Vomiting Sore
mouth
T-erm/full term deliveries, 37 completed weeks or more "What are your food restrictions or preferences?"
P-reterm deliveries, 20 to less than 37 completed weeks A- "Any supplements (vitamins, feeding)?"
bortions; elective or spontaneous loss of pregnancy before the "Has your weight changed prior to pregnancy?" If yes, why?"
period of viability (less than 20 weeks) L-iving children a woman
has delivered 3. ELIMINATION PATTERN
M-ultiple gestations and births (not the number of neonates Bladder
delivered) "Are there any problems or complaints with the usual pattern of
 Date of LMP (first day of last menstrual period) urinating?"
 Estimated Date of birth-expected date of Oliguria Polyuria
confinement/ delivery Dysuria Dribbling
 Signs and symptoms of pregnancy, amenorrhea, Retention Stress Incontinence
breast changes, nausea and vomiting, urinary Burning
frequency, skin pigmentation, enlargement of the
abdomen, fetal movement. Bowel
"What are the usual time, frequency, color, consistency, and
✓ Past Obstetric History pattern?"
• Problems of infertility, maternal, fetal and neonatal "Assistive devices (type, frequency)?"
complications Enemas Laxatives
• Woman's perception of past pregnancy, labor and delivery Catharics Suppositoriees
for herself and effect on her Family
4. ACTIVITY-EXERCISE PATTERN
Date Duratio Sex Weig Metho Place remar "Describe usual daily/ weekly activities of daily living."
of n of of ht of d of of ks Occupation
deliver Labor bab baby deliver deliver Leisure activities
y y y y Exercise pattern (type, frequency)
"Do you work outside the home?"
"Are there factors present that could interfere with activities at
✓ Medical History home (self-care, home care)?"
Lack of knowledge
➤ Childhood diseases (e.g. rubella, chicken pox) Lack of resources
➤ Major illnesses, surgery (especially of the reproductive tract),
blood transfusions 5. SLEEP-REST PATTERN
➤ Drug, food, environmental allergens "What is the usual sleep pattern?"
➤ Urinary infections, heart disease, diabetes, hypertension, Bed time Hours slept
endocrine disorders, anemias Sleep Aids Sleep routine
➤ Use of oral or other contraceptives "Any problems?"
 History of STD  Difficulty falling asleep
 Menstrual history-start of menarche, duration, amount,  Difficulty remaining asleep
regularity and pain (dysmenorrhea), bleeding between  Not feeling rested after sleep
periods (metrorrhagia)
➤ Use of medications - prescriptions, OTC, other drugs, alcohol, 6. COGNITIVE-PERCEPTUAL PATTERN
tobacco, caffeine "Any deficits in sensory perception (hearing, sight, touch)?"
➤History of TB, hepatitis, group B beta streptococcus, HIV Glasses
Hearing aid
✓ Family History (Genogram) "Any complaints?
Vertigo
➤ Maternal and paternal history Insensitivity to superficial pain
Insensitivity to cold or heat
"Able to read & write?"
 7. SELF-PERCEPTION PATTERN
"What are you most concerned about?"
"What are your present health goals?"
"How would you describe yourself?"
"How do you think your life will change with this baby?"

8. ROLE-RELATIONSHIP PATTERN
Relationships
"To whom do you turn to in time of need?"
Assess family life (members, educational level, occupations)
 Cultural background
 Decision making
 Activities (lone or group)
 Communication patterns
 Roles
 Finances
Assess for
 Parenting difficulties
 Difficulties with relative (in-laws, parents)
 Marital difficulties
 Abuse (physical, verbal, substance)

SEXUALITY-REPRODUCTIVE PATTERN
Age at menarche
Contraceptive use (type, years of use)
Leukorrhea, vaginal itching, postcoital bleeding, pain or cystitis
Sexual activities
"Have you been satisfied with the quality & quantity of your sexual
activities (your partner)?"
Any pain or discomfort with intercourse?""
"Has there been or do you expect a change in your sexual relations
(related to pregnancy, child care, breast-feeding)?"

10. COPING- STRESS PATTERN

"How do you make decisions (alone, with assistance, who)?"
"Has there been a loss in your life in the past year (or changes
moves, job, health)?"
"What do you like about yourself?"
"What would you like to change in your life?"
"What is preventing you?"
"What do you do when you are tense or under stress (eg, problem-
solve, eat, sleep, take medications, seek help)?"

11. VALUE-BELIEF SYSTEM

"With what (whom) do you find a source of strength or meaning?"