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?

which health clinic? __________________ which unit? _______________ 5. upset?) How do you feel about it now? ___________________________________________________________________________ 6. How did you feel about being pregnant when you first found out? (For example: pleased. not sure. Have you been to the prenatal clinic/seen a doctor for pregnancy care? __Yes __No If yes. Have you had any illness or complications prior to pregnancies/deliveries? __Yes__No Explain: _______________________________________________________________ PHYSICAL ASSESSMENT . How many times have you been pregnant? 4.3.

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______________________________________________________________________________ . 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.NURSING REVIEW OF SYSTEMS (circle the appropriate symptoms) 1. 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.

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 .6.

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