Marist Brothers

Notre Dame of Marbel University

College of Arts and Sciences
Nursing Department

INTRA PARTAL ASSESSMENT GUIDE

Name of Student: _____________________________________ Dates of Exposure: ___________________________

Clinical Instructor: ____________________________________ Area of Exposure: ____________________________

I. Vital Information

Name: Date of Interview:

Age: Informant:
Address: Relationship to Patient:
Partner’s Name:
Partner’s Age:
Civil Status:
Religious Affiliation:
Date of Delivery:
Time of Delivery:
Educational Attainment:
Date and Time Admitted:
Weight:
Height:
Physician’s Initial:
Chief complaints:
Diagnosis:
Days Post-op (if CS):

II. Obstetrical History

G___ P___T___P___A___L___ Last Menstrual Period:

Estimated Date of Confinement: Age of Gestation:
Pad Counts: Duration of menses:
Prenatal Check-up:
( ) Yes; number of visits: _____________
Healthcare provider: ______________
( ) No
Discomforts on present pregnancy:

Medications taken during pregnancy

Medication Duration Frequency Dosage

III. Labor Watch

Intensity Duration Frequency Interval
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Length of Labor:

IV. Labor Record

Duration of Pregnancy:
Onset of Labor:
Type of Delivery: ___ Normal ___Operative
Date and time of delivery:
Blood loss:

Anesthesia:
Amount:
Given by:

Laceration: ___Mucous ___Skin ___Vagina ___Bilateral

Suture Used:

BOW:

V. Infant Data
Sex:
Weight (kg):
Length (cm):
Head Circumference (cm):
Chest Circumference (cm):
Abdominal Circumference (cm):

APGAR Score:
Score
Criteria
1st Minute 5th Minute
Appearance
Pulse
Grimace
Activity
Respiration

Vital Signs:
Temperature:
Pulse Rate:
Respiratory Rate:

Medications and Vaccines

Rationale Nursing Responsibilities Administered by

Eye ointment

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 Vitamin K

Hepatitis B

BCG

Placenta
Method of delivery:
Time:
Type:

Abnormalities and complications:

VI. Laboratory / Diagnostics

1. Clinical Chemistry

Name of Examination:
Definition:
Preparation:
Purpose:
Date:

2. Clinical Hematology

Name of Examination:
Definition:
Preparation:
Purpose:
Date:

3. Clinical Microscopy

Name of Examination:
Definition:
Preparation:
Purpose:
Date:

4. Radiologic Exams
Name of Examination:
Definition:
Preparation:
Purpose:
Date:

VII. Textbook Discussion

Patient’s Labor Labor according to textbook

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 Reference:
Patient’s Delivery Delivery according to textbook

Reference:

VIII. List of Nursing Problems

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10.

IX. Health Teachings

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10.

X. Data for Exhibit

Name of Patient: _______________________________

Name of Hospital: ______________________________
Hospital Number: ______________________________
Case Number: __________________________________
Nurse on Duty: ________________________________
Head Nurse: ___________________________________
Physician on Duty: _____________________________
Midwife on Duty: ______________________________

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