NCM 109 OB Patho Assessment Tool

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XAVIER UNIVERSITY O2 Sat_____ Ht______ Wt._____ BMI: ______ Duration of menstrual flow___________days
ATENEO DE CAGAYAN Interpretation of BMI: ____________________________ Amount of Menstrual Flow__________
COLLEGE OF NURSING III. Past Obstetric/Medical/Surgical History Menstrual Discomfort:________________________________
NCM 109 RLE Illness Date Vaginal discharge (odor,
OBSTETRIC PATHOLOGIC ASSESSMENT TOOL color)__________________________
SN Name: _________________________ Block:_____ Bleeding between
Area of Exposure_________________CI:___________ periods______________________________
I.GENERAL INFORMATION Sexually active_____ Sexual
Name:_____________________________ Age:______ IV. History of Family Illnesses (Check box that applies) concerns/difficulties____________
Birthday:_______________Civil Status:_____________ Hypertension Recent change in
Sex:___ Religion:__________ Occupation:___________ Coronary Artery Disease (CAD) frequency/interest______________________
Income:___________Address:____________________ Cerebro-vascular Disease(CVD) Reproductive Tract
_____________________________________________ Diabetes Mellitus Surgery:_____________________________
Informant:________________Relation:_____________ Kidney Disease Reproductive Family Planning Methods
Admission Date:_______________ Time:____________ Tuberculosis Used:_______________
Chief Complaint:________________________________ Cancer For how
Attending Physician_____________________________ Others (Specify): _____________________________ long:_________________________________________
Diagnosis/Impression____________________________ Side Effects if
II. History of Present Illness: V. Obstetric History (Pregnancy, Labor and Birth) any:_____________________________________
_____________________________________________ Para:______Gravida:_________TPAL: _________________ Previous
_____________________________________________ Prenatal Care Coverage:____________________________ Miscarriages/Abortion__________________________
_____________________________________________ Place of Prenatal Care:______________________________
_____________________________________________ Total number of visits:______________________________
______________________________________________ Any abnormal findings: _____________________________ VII. ASSESSMENT OF SYSTEMS
Current Medications: (include Dosage,Timing , Route and Pre-pregnancy Weight: _____________________________ Objective
Indication of use): Weight Gain: _____________________________________ General Appearance and Mental Status_______________
Name, dose, timing, route Indication Last Menstrual period______________________________ Personal Hygiene/Habits___________________________
EDC:____________________________________________ Hair______________________________________
Age of Gestation:__________________________________ Clothing/Manner of Dress_____________________
VI. Gynecologic History Body Odor_________________________________
Age of Menarche_______________________ Speech: _______ clear ______ slurred
Menstrual Cycle: _______uninteligible ________ Aphasic
Upon assessment:
Interval/ Length of cycle___________ days Subjective
Vital Signs: HR______ RR______ BP_______ Temp______
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Pain: Precipitating: ____________________________ Nose Leopolds’s Maneuver____________________________

Quality of Pain: _______________________________ Nasal Congestion______________________ Fetal Position___________________________________
Radiating at: ______________Severity: ___________ Time: Sense of smell:____________________________ Pelvic Measurement_____________________________
(Onset, Frequency, Duration) Epistaxis_________________________________
___________________________________________ Others/Comments:_________________________ Circulation
Others/Comments________________________________ ________________________________________ Ankle/Leg edema_________________________________
Others/Comments:___________________________ History of Hypertension____________________________
Head and Scalp Mouth, Teeth and Throat Extremities: Numbness______________Tingling:________
Symmetry_______________________ Objective Change in frequency/amount of urine_________________
Contour___________ Distiribution___________________ Condition of mouth______________________________ Homan’s sign_____________________________________
Thickness_______________ Excessive Condition of teeth and gums_______________________ Others/Comments:________________________________
Dryness/Oiliness_____________ Use of hair dye________ Appearance of tongue____________________________ ________________________________________________
Lesions: ________________________________________ Gingival gum hypertrophy_____________ Lesions_______
Dental hygiene___________ Dental Carries____________ Objective
Subjective: BP: R: Lying_______________ Sitting________________
Headache____ Location__________Frequency_____ Neck/Lymph Nodes L: Lying_______________ Sitting________________
Fainting spells/dizziness________________________ Objective Heart sounds: Rate_________ Ryhthm_______________
Tingling/numbness/weakness (location)___________ Thyroid hypertrophy__________________________ Pulse: Carotid______ Radial________ Popliteal_______
___________________________________________ Palpable lymph nodes_____________________________ Temporal____ Femoral_______ Dorsalis Pedis____
Others/Comments:___________________________ Breasts Capillary refill_______________ Color___________________
___________________________________________ Objective Cyanosis/Pallor_____________________________________
Eyes/Ears Breasts changes: Areola ______________ Breast Varicosities________________________________________
Objective Size_________ Presence of Nail beds:__________________________________________
Edema in eyelids_____________________________ Colostrum_________________________________ Mucous membranes_________________________________
Sclera & Conjuctiva__________________________ Adequacy of breast for Others/Comments:________________________________
Spots before the eyes________________________ breastfeeding_____________________ ________________________________________________
Diplopia(double vision)_______________________ Abnormal
Subjective signs_______________________________________ Respiration
Vision loss: R____________ L________________ Perform BSE (frequency and schedule)___________________ Objective
Last examination:__________________________ Respiratory Rate______ Depth________ Symmetry______
Ears: Hearing loss: ____________ Abdomen Use of accessory muscles_________ Nasal flaring________
Last Examination:__________________________ Objective (antepartum) Abnormal Breath sounds______________________________
Fundal Height: ________________________________ Cyanosis________________ Clubbing of fingers___________
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Sputum characterisitics_____________________________ Last BM: _____________________ Financial concerns_________________________________

Others/Comments:__________________________________ Recent: Character of stool____________________________ Relationship status________________________________
______________________________________________ Amount: ___________ Frequency: ______________ Lifestyle_________________________________________
Dyspnea related to___________________________ Color: _____________ Odor: __________________ Recent changes________________________________
Cough/sputum______________________________ History of GI bleeding__________ Hemorrhoids_________ Feelings of helplessness________ Hopelessness_________
History of: Constipation________________Laxative use____________ Powerlessness________________________
Bronchitis____ Asthma_____ Tuberculosis_______ Others: ___________________________________________ Others/Comments________________________________
Emphysema_____ Recurrent Pneumonia________ _______________________________________________
Smoker_______ Pack/day________ Number of years____ Usual voiding pattern:______________ Incontinence______ Objective
Use of respiratory aids___________ Oxygen___________ Urgency________ Retention________ Frequency______ Emotional Status (check those that apply)
Others/Comments:_______________________________ Pain/Burning/Difficulty in voiding___________________ Calm ________ Anxious________ Angry___________
______________________________________________ History of kidney/bladder disease___________________ Withdrawn______ Fearful ______ Irritable________
Others/Comments:________________________________ Euphoric________
Food/Fluid Intake _______________________________________________
Subjective
Usual diet (type)________ No. of meals daily_________ Safety
Last meal intake_________ Loss of appetite____________ Activity and Rest Subjective
Nausea/vomiting_____________ Dentures_____________ Subjective Allergies/sensitivity_______________________________
Allergy/Food Intolerance___________________________ Usual activities/hobbies:____________________________ Reaction________________________________________
Heartburn/Indigestion_____________________________ Leisure time activities______________________________ History of STD(Date/Type)__________________________
Mastication/swallowing problems____________________ Limitations imposed by conditions____________________ Blood Transfusion/number_________ When___________
Changes in weight_________________________________ Sleep: History of accidental injuries________________________
Diuretic use_________________ Number of hours__________ Naps_____________ Fractures/dislocations_____________________________
Sleeping Aids _________________ Arthritis/unstable joints___________________________
Objective Difficulty in sleeping_________________________ Back problems___________________________________
Current weight_______ Height______ Body build_______ Feeling on awakening________________________ Changes in moles_______________ Enlarged nodes_____
Skin turgor___________ Mucous membranes Others/Comments:__________________________________ ________________ Unusual bleeding_________________
moist/dry_____________ Hernia/masses______________ __ Prosthesis______________________________________
Other Comments: _________________________________
Ego Integrity
Elimination Subjective
Subjective Report of stress factors_____________________________
Usual bowel pattern______________________________ Ways of handling stress____________________________
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Social Interactions Laboratory/Diagnostic Results (Include date and interpret in

Subjective: relation to patient’s condition.)
Marital status_________ Years in relationship__________
Living with________________________________ a.CBC
Concerns/stresses__________________________
Extended family_________________________________
Other support person_____________________________
Role within family structure________________________
Report of problems related to illness/condition________ b.U/A
______________________________________________
______________________________________________
Others/Comments_______________________________
c. Fecalysis
Teaching/Learning
Subjective
Dominant language(specify)________________________
Literate________ Educational level__________________ Describe affected
areas_________________________________
Health beliefs/practices___________________________ _________________________________________________ d. X-ray/ Sonogram
______________________________________________ _________________________________________________
______________________________________________
Body Map. (Illustrate in the body map how your patient looks
like e.g. tubes inserted, bruises, surgical incisions,
physical abnormalities, affected areas. Mark with a small “x”
where it is located or draw it on the body map and then
label.)
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1

Pain: Precipitating: Nose Leopolds’s Maneuver

Sputum characterisitics___________________ Last BM: _ Financial concerns_______________________

Social Interactions Laboratory/Diagnostic Results (Include date and interpret in

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