C.

MATERNAL ADMISSION AND ASSESSMENT

Name of Student:
Name of Clinical Instructor:

Clinical Assignment:
Inclusive Dates:

GENERAL ADMISSION INFORMATION

Physical Appearance: _________________________________________________________________

____________________________________________________________________________________
Content of Conversation: _____________________________________________________________
____________________________________________________________________________________
Social Economic History
a.
Native Language:
b.
Occupation:
c.
Financial Status (what is the impact of current hospitalization):
d.
Civil Status:
Married_____
Single_____
Divorced______ Widowed
______
e.
Living
Situation:
Lives
Alone
_______________________________________________________
Living with other (specify) _____________________________________________
Past Medical History
a. Medical:
b. Surgical:
c. Medications:
d. Traumatic Injuries:
e. Orthopedic:
f. Other (psychiatric, etc.):
g. Habits: Smoking:______________________ Alcohol:________________________
PREGNANCY INFORMATION
1. Is this your first baby? ___ Yes ___ No
2. How many children do you have?

3. How many times have you been pregnant?

4. Have you been to the prenatal clinic/seen a doctor for pregnancy care? __Yes __No
If yes, which health clinic? __________________ which unit? _______________
5. How did you feel about being pregnant when you first found out? (For example: pleased, not sure,
upset?) How do you feel about it now?
___________________________________________________________________________
6. Have you had any illness or complications prior to pregnancies/deliveries? __Yes__No
Explain: _______________________________________________________________

PHYSICAL ASSESSMENT

NURSING REVIEW OF SYSTEMS (circle the appropriate symptoms)

1. EENT:
Headaches
Hearing loss
Visions
Diplopia
Eye pain
Eye infection
Blurring
Epistaxis
Sinus pain
Facial pain
Bleeding gumsDentures
Sore throat
Nasal-tracheal pain Other ______________________________
2. CARDIO-RESPIRATORY: Chest pain (site) __________________________________________________
Chest pain with exertion
Dyspnea on exertion
Nocturnal dyspnea
Edema
Hypertension
Palpation
Known murmur
Cough
Sputum
Hemoptysis
Pleuritic pain
Diaphoresis
Last X-ray:
EKG:
3. GASTRO-INTESTINAL
Thirst
Nausea
Vomiting
Hematemesis
Heartburn
Difficulty in swallowing
Flatulence
Constipation
Abdominal pain
Jaundice
Diarrhea
Tarry stool
Hemorrhoids
Hernia
Others_________________________
4. GENITO-URINARY:
Dysuria
Polyuria
Frequency
Urgency
Nocturia
Burning
Hematuria
Stones
Female Genital Tract Menstrual History:
Age of Onset: ___________________________
Frequency ____________ Regularity __________________ Duration___________________
Post menopausal bleeding ______________________________________________________
Age _____________ Symptoms _________________________________________________
5. MUSCULO-SKELETAL:
Muscle pain
Extremity pain
Joint pain
Back pain
Joint swelling
Neck pain
Stiffness
Limited motion
Redness
Sprains
Deformity
Other______________________________________________________________________________

6. NERVOUS :
Convulsions
Syncope
Dizziness
Vertigo
Tremor
Speech Difficulty
Limp paralysis
Peresthesia
Muscle atrophy
Muscle tenderness
EEG______________________________________________________________________________
7. ENDOCRINE
Goiter
Tremor
Heat or Cold intolerance
Exopthalmos
Voice Change
Polydipsia
Change in body contour
Infertility
Others____________________________________

SOCIAL SUPPORT
Describe the kind of support client gets from family:
______________________________________________________________________________
______________________________________________________________________________

____________________________
Signature of Student

________________________________
Signature of Clinical Instructor