UNIVERSITY OF BALAMAND

Faculty of Health Sciences

Nursing Program
NURS 247 Assessment Tool (Pregnancy/Delivery/PPP)

Student Name _______________________Clinical date ________________

GENERAL INFORMATION /5
Initials Age
Admission Date Room nb
Health insurance Blood group/Rh
Woman Education level Husband Education level
Woman occupation Husband occupation
Economic level Husband blood group/Rh
P0000 LMP EDD Gestational age
Reason for admission
PRESENT HISTORY [5-6 lines]

PAST MEDICAL HISTORY (that might interfere with pregnancy, delivery and PP) /5
• Women History of:
Diabetes GI disease ( ulcer, gallbladder) UTI
Heart Disease Hypertension Blood incompatibility
Varicose vein Phlebitis Hepatitis B
HPV vaccine Rubella vaccine Immunity to Toxoplasmosis
Congenital anomalies:
Drug allergy (specify and describe)
Surgeries (type and date)
History of previous pregnancies [date of occurrence, progress, mode of delivery, outcome, health status
of the children]:
Others:
• Family History of:
Diabetes Hypertension Heart Disease
Multiple pregnancies Congenital anomalies Cancer
Other
Nursing Diagnosis

• PRENATAL PERIOD /5
Current health problems
Visual disturbances Edema
Headache Vaginal discharge
Bleeding Water breaks
High Blood Pressure Proteinuria
Varicose veins

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MA & PG, 19-20
 Laboratory studies
Medication during pregnancy
Other
Nursing Diagnosis

• INTRAPARTUM PERIOD /5
Beginning of labor (date and hour)
Uterine contractions FHR
Cervical effacement and dilation
Fetal presentation Station
Membranes Amniotic fluid
Laboratory studies
Brief overview about the process of labor [2 - 3 lines]

Others
Nursing Diagnosis

• DELIVERY/BIRTH /5
Date and hour
Mode of delivery [if not normal, specify the reason]
Normal Complete
Delivery of the placenta Hour:
Manual Incomplete
Cervical/Vaginal lacerations Episiotomy (type)
Lochia
Uterine tone
Medications/anesthesia:
Others
Nursing Diagnosis

• POSTPARTUM PERIOD (PPP) /5

Postpartum day
Fundus (involution, position, any tenderness with touch, tone)
Lochia (color, amount, etc)
Breasts (shape and consistency)
Perineum/episiotomy/ cesarean wound (describe)type
Others
Nursing Diagnosis

HEALTH MAINTENANCE-PERCEPTION PATTERN /5

• PRENATAL PERIOD

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MA & PG, 19-20
 Habits (frequency and amount)
Coffee Tea
Herbal Preparation Soft Drink
Alcohol Smoking/Argyle: active/passive
Other
Specific measures taken by the patient to promote health
1. Weight management
2. Regular exercise (specify what kind and how often)
3. Regular physical exam and screening tests (specify frequency, type of tests and results)
4. Auto-Surveillance
5. Recent changes in lifestyle
6. Other
Nursing Diagnosis

NUTRITION-METABOLIC PATTERN /10

• PRENATAL PERIOD
Weight Before conceiving
Weight gain Height
Current weight
Nausea Vomiting Heart burn Indigestion
Describe the diet & hydration
Water intake (glasses/d) Milk intake (glasses/d)
Juice intake (glasses/d) Others
Number of meals per day/type (describe)
Number of snacks per day /type (describe)
Appetite (describe)
Food Allergy/ intolerance (specify)
Skin State:
Intact Color Rash
Dry Moist Swollen
Wounds/drains [specify]:
Striagravidarum Chloasm
Other
Oral Hygiene:
Last dental exam Condition of teeth
Mastication/Swallowing problems
Bleeding of gums
Oral herpes currently or in the past [specify]
Other
Nursing Diagnosis

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MA & PG, 19-20
 • INTRAPARTUM PERIOD
Last meal (time/describe):
• PPP
Breastfeeding (Describe)
Nutrition
Knowledge about nutritional needs during breastfeeding:
Skin State
Nursing Diagnosis

ELIMINATION PATTERN /10

• PRENATAL PERIOD
Gastrointestinal function:
Frequency/24h
Diarrhea Constipation Use of laxatives
Hemorrhoids Abdominal gases/flatus
Urinary function
Frequency/24h: Colour
Burning sensation UTI
Stress incontinence
Nursing Diagnosis

• PPP
Gastrointestinal function:
First defecation after delivery: Frequency/24h:
Diarrhea Abdominal gases/flatus
Constipation Hemorrhoids
Use of laxatives /enemas
Absent (location)
Bowel Sounds Hyperactive Hypoactive
Others
Urinary function
First urination after delivery Frequency/24h
Urine color Hematuria
Burning sensation Incontinence
Urinary retention or incontinence
Foley (insertion/removal/duration)
First voiding after removal
Quantity and Colour of urine
Others
Nursing Diagnosis

4
MA & PG, 19-20
 ACTIVITY-EXERCISE PATTERN /10
• PRENATAL PERIOD
Respiratory
RR
Dyspnea (precise) Cough
Infection (precise) Allergy
Cardiovascular
BP Ankle/leg edema (describe)
Varicosities/Location Limitation in ADL’s/Mobility impairments
Other
Nursing Diagnosis

• INTRPARTUM PERIOD
BP Pulse ToC RR
• ppp
Respiratory
RR
Dyspnea (precise) Cough
Infection Allergy
Other
Cardiovascular
BP Pulse To C
Kegel exercise Early ambulation post delivery
Homans’ sign Phlebitis
Ankle/leg edema (describe) Varicosities/Location
Limitation in ADL’s/Mobility impairments
Other
Nursing Diagnosis

SLEEP-REST PATTERN /5
• PRENATAL PERIOD
Calm Naps
Quality of sleep Hours per day
Insomnia Disrupted
• PPP
Quality of sleep
Measures to promote rest and sleep
Nursing Diagnosis

5
MA & PG, 19-20
 COGNITIVE-PERCEPTUAL PATTERN /10
Equilibrium
Hearing
Vision
Communication
Pain during pregnancy
Nursing Diagnosis

• INTRAPARTUM PERIOD
UC (describe)
Scale of pain
Pain management
Level of stress-anxiety
Nursing Diagnosis

• PPP
Pain: location
Perineum Hemorrhoids Afterpain
Abdominal incision Gazes Breasts
Other
Pain scale
Pain management
Worries about:
Parental role Newborn care Breastfeeding
Body image Personal care Activities
Nursing Diagnosis

COPING-STRES TOLERANCE/SEL–PERCEPTION/SELF-CONCEPTPATTERN /5
Have you planned for this pregnancy?
How does your husband feel?
Describe your current emotional status regarding pregnancy, delivery, Newborn and breastfeeding:

Mechanism of adaptation
Nursing Diagnosis

SEXUALITY-REPRODUCTIVE PATTERN /5
First menarche Length of cycle Length of period
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MA & PG, 19-20
 Regular Irregular
Vaginal discharge Dysmenorrhea
Itching Infections (genital or STD)
Breasts disorders Ovarian disorders
Fertility problems
Breast self-examination
Last pap smear/results
Family Planning
Other
Nursing Diagnosis

ROLE-RELATIONSHIP PATTERN /7.5

Significant persons
Quality of family interrelation
Family responsibilities
Difficulties related to childbearing/childrearing in the accomplishment of the role [parents’ feelings/
reactions/attitude/behavior]:

Readiness for breastfeeding

Mother-Father-Infant interaction/bonding/Skin to skin/Rooming-in [parents’ feelings/reactions/ attitude/
behavior]:

Nursing Diagnosis

VALUE-BELIEF PATTERN /2.5

Interference of religious practice with childbearing and childrearing (Describe)

Nursing Diagnosis

Progress note/5

Day 1:
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MA & PG, 19-20
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MA & PG, 19-20
 UNIVERSITY OF BALAMAND
Faculty of Health Sciences
Nursing Program
NURS 247 Assessment Tool (Pregnancy/Delivery/PPP)

Nursing Care plan

Nursing Diagnoses in Priority Order /10

Nursing process /45

(Each NP/15)

Nursing Diagnosis Expected

/ Problems in Scientific Outcomes / Nursing Rationale of the Evaluation/2
Collaboration Explanation/2 Nursing Interventions /5 Interventions/3
Objectives/3

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MA & PG, 19-20
 10
MA & PG, 19-20