WEEK _

Item Points

_______________________
Clinical Instructor
 GENERAL OBJECTIVE AND SPECIFIC OBJECTIVES (GOSO)

HRN : ___________________________________ Date: _______________

Hospital: __________________________________ Shift: _______________
Clinical Instructor: ___________________________ Area: _______________

GENERAL OBJECTIVE
1ST DAY 2ND DAY

SPECIFIC OBJECTIVES
1ST DAY 2ND DAY
Knowledge
1. 1.

2. 2.

Skills
1. 1.

2. 2.

Attitude
1. 1.

2. 2.

CLINICAL TEACHING PLAN

Activities
Time ST
1 Day 2ND Day
 MATERNAL ASSESSMENT

Instructions: Kindly fill out the information below through interview of the patient
or his/her significant others. Other information will be acquired through direct
patient assessment and patient’s chart. Be sure to write it legibly and accurately.

I. PATIENT’S PROFILE

HRN : Age :
Address : Birthdate:
Civil Status : Weight :
Religion : Height :
Educational Attainment : Blood Type :
Occupation : HBSAg :
Ethnic Group : Vital Signs
Admission Date & Time : BP:
Health Insurance : Temp.:
Attending Physician : RR:
Clinical Diagnosis : PR:
FHT:
Site/Area:

II. CLIENT’S HEALTH HISTORY

a. Obstetric / Gynecologic History

Age of Menarche: Menstrual Cycle:

LMP : Interval:
EDC : Frequency:
AOG : Duration:

Gravida: ______ Parity: ______ [T: _____ P: _____ A: _____, L: _____]

b. Complications/Risk Factors

[ ] Age (below 18 and above 35) [ ] Multiple Pregnancy

[ ] Ovarian Cyst [ ] Placenta previa
[ ] History of still birth [ ] History of 3 Miscarriages
[ ] History of pre-eclampsia/eclampsia [ ] Uterine Myoma
[ ] Others: (please specify) ___________________________________________

III. STAGES OF LABOR

a. FIRST STAGE – From the True signs of labor to full cervical dilation.

i. Latent Phase – The time of the onset of labor until the cervix is dilated
to 3 cm.

Time Started : Time Membrane Ruptured :

Intensity : Cervical Dilatation:
Duration : Effacement:
Frequency :
 ii. Active Phase – Continues from 4 cm. until the cervix is dilated to 7
cm.

Time Started : Time Membrane Ruptured :

Oxytocin Stimulation : [ ] Spontaneous [ ] Artificial
Duration of this phase:
Complications (any) :
Medication given : [ ] Yes [ ] No

Date & Time Medication/s & Dosage Route/Site

Note: During this phase, contraction intensity is stronger, interval shortens, and
duration lengthens. This is where true discomfort is first felt by the patient
so she is dependent and her focus is on herself. Therefore, it is vital to
monitor the mother’s progress of active phase. Labor watch monitoring
sheet is on the next page in a tabular form.

iii. Transition Phase

Time Started : Duration of this phase:

Episiotomy : [ ] Yes [ ] No
If Yes : [ ] Mediolateral [ ( ) Right ( ) Left ]
[ ] Median
Vaginal Tear : [ ] 1st Degree Vaginal Tear or Laceration
[ ] 2nd Degree Vaginal Tear or Laceration
[ ] 3rd Degree Vaginal Tear or Laceration
[ ] 4th Degree Vaginal Tear or Laceration

Note:
➢ First-degree tear: laceration is limited to the fourchette and superficial perineal skin or
vaginal mucosa
➢ Second-degree tear: laceration extends beyond fourchette, perineal skin and vaginal
mucosa to perineal muscles and fascia, but not the anal sphincter
➢ Third-degree tear: fourchette, perineal skin, vaginal mucosa, muscles, and anal
sphincter are torn; third-degree tears may be further subdivided into three subcategories:[6]
o 3a: partial tear of the external anal sphincter involving less than 50% thickness
o 3b: greater than 50% tear of the external anal sphincter
o 3c: internal sphincter is torn
➢ Fourth-degree tear: fourchette, perineal skin, vaginal mucosa, muscles, anal sphincter, and
rectal mucosa are torn
 LABOR WATCH MONITORING SHEET

Time FHT Location Vital Signs Duration Frequency Interval

Started Ended BP RR PR Temp.

Note:
➢ Duration – from the beginning of one contraction to the end of the same contraction.
➢ Frequency – from the beginning of one contraction to the beginning of the next contraction.
➢ Interval – resting time between contractions which allows placental perfusion
The Leopold’s Maneuver

Instructions: Perform the Leopold’s Maneuver and make sure to fill – out the table
below with the pertinent findings assessed to the patient. Be sure to write it legibly.

Maneuver Description Result / Findings

First
Maneuver

Second
Maneuver

Third
Maneuver

Fourth
Maneuver
 b. SECOND STAGE – from the full cervical dilatation to expulsion of the
baby.

Time of Birth : Baby’s sex

Type of Delivery : Duration:
Fetal Presentation :
Episiotomy : [ ] Yes [ ] No
If Yes : [ ] Mediolateral [ ( ) Right ( ) Left ]
[ ] Median
Vaginal Tear : [ ] 1st Degree Vaginal Tear or Laceration
[ ] 2nd Degree Vaginal Tear or Laceration
[ ] 3rd Degree Vaginal Tear or Laceration
[ ] 4th Degree Vaginal Tear or Laceration

Oxytocin given? : [ ] Yes [ ] No Time:

Dose & Route :

c. THIRD STAGE – Placental Stage

Time of Placental Expulsion: ___________________ Duration: _____________

Placental presentation : ( ) Complete ( ) Incomplete
Placental Delivery : ( ) Spontaneous ( ) Cord Traction
( ) Manual Removal
Condition of Cervix : ( ) Lacerated ( ) No Laceration
Estimated Blood Loss : ___________ ml
Anesthesia/Analgesic given
Date & Time Medication/s & Dosage Route/Site

d. FOURTH STAGE – 1 hour after expulsion of placenta. Focuses on the

mother’s current condition.

i. Record the vital signs every 15 minutes or as per physician’s

order using the table below for both the mother and neonate.

Time Mother Neonate

BP RR PR Temp. O2 RR PR Temp. O2
Sat Sat
 ii. Monitor and note the condition of the uterus according to the physician’s
order. Please indicate the exact time when you assessed your patient.

Time Condition of the Nursing Responsibilities

Uterus

1-hour post –
partum

__________

2-hours post –
partum

__________

3-hours post –
partum

__________
 INTRAPARTAL NURSING RESPONSIBILITIES

STAGES
OF LABOR DESCRIPTION NURSING RESPONSIBILITIES

FIRST
STAGE OF
LABOR

SECOND
STAGE OF
LABOR

THIRD
STAGE OF
LABOR

FOURTH
STAGE OF
LABOR
 PARTOGRAPH
Instruction: Please use this form for monitoring active labor of your client.
 BREASTFEEDING MONITORING

Instructions: Assess the breastfeeeding positioning and attachment. Monitor and note your observations.

Date & Time of Initiation : _________________________ Average Breastfeeding Duration : ______________________________

Positioning Breastfeeding
Timing Actual Time Chin on Chin to Support Mouth wide Lower lip Chin Suckling
Breast breast whole body open turned touching slow and Nursing Responsibilities
onward breast deep

15
mins

30
mins

45
mins

1 hr
PP
 NURSE’S NOTES

Date & Time Focus Data – Action – Reaction/Response

 NEWBORN PHYSICAL ASSESSMENT

Instructions: Kindly fill out the information below through interview of the patient
or his/her significant others. Other information will be acquired through direct
patient assessment and patient’s chart. Be sure to write it legibly and accurately.

1. PATIENT’S PROFILE

HRN : Date :
Birth Date : Sex :
Gestational Age : Weight :

APGAR Scoring 1 minute 5 minutes

Heart Rate
Respiratory Rate
Muscle Tone
Reflex Tone
Color
TOTAL:

Anthropometric Measurements
Vital Signs: Head Circumference: _______ cm
T = ______ __ Chest Circumference: _______ cm
HR = ______ __ Abdominal Circumference: _______ cm
RR = ______ __ Length: _______ cm
O2 Sat = _____ Birth Weight: _______kg

2. RESPIRATORY EFFORT:
Retractions: _______________ Grunting: _______________
Quality of Cry: _______________

3. AUSCULTATE FOR:
Retractions: _______________ Grunting: _______________
Quality of Cry: ____________

4. SKIN :

Color Texture
Jaundice Lanugo
Mongolian Spots Turgor
Harlequin’s Sign Milia
Vernix Caseosa Erythema Toxicum
Telangiectatic Nevi Mottling
Vasculosus Nevus Flammeus
Pallor Acrocyanosis
Hemorrhagic Sites Marks
Ecchymosis petechiae
Breaks
5. HEAD :

Hair Texture :_______________________________________________

Anterior Fontanel : [ ] bulging [ ] depressed [ ] normal
Posterior Fontanel : [ ] bulging [ ] depressed [ ] normal
Molding : [ ] Present [ ] absent
Facial Symmetry : __________________________________
Caput Succedaneum : _______________________
Cephalhematoma : __________________________________

6. EYES :

Position : [ ] Symmetrical [ ] Asymmetrical

Blink reflex : [ ] Present [ ] Absent
Conjunctival hemorrhage : [ ] Present [ ] Absent
Discharges : [ ] Watery [ ] Sticky [ ] None
others pls. specify: ___________________________________________

7. EARS :

Placement / Position : [ ] Low Set [ ] High Set

Pinna flexibility : [ ] flexible [ ] inflexible
Ear Tags : [ ] Present [ ] Absent
Occlusion : [ ] Partial [ ] Complete [ ] None

8. NOSE :

Nares patency : [ ] patent [ ] occluded [ ] nasal flaring

Discharges : [ ] Present [ ] Absent

9. MOUTH/THROAT :

Uvula placement: ___________________________

Present of Precocious Teeth : _______________
Palate/lip : ( ) hard ( ) soft ( ) opening
Mucous Menbranes color : ( ) pink ( ) moisten ( ) cyanotic ( ) dry
Reflexes : ( ) sucking ( ) rooting ( ) gag ( ) extrusion ( )swallowing
Tongue : _______________________
Cry :( ) weak ( ) strong

10. CHEST

Shape : ( ) funnel ( ) barrel

( ) pigeon ( ) Anteroposterior:lateral (1:1)
Nipple : ( ) inverted ( ) firm ( ) red
( ) others, pls specify: ______________________________
Breast Engorgement : ( ) present ( ) absent
Chest excursion/retraction:( ) symmetrical ( ) asymmetrical
Supernumery Nipples : ( ) present ( ) absent
Witch’s Milk : ( ) present ( ) absent
Breath Sounds present: ( ) rales ( ) crackles ( ) wheeze
( ) stridor ( ) clear
Heart Sound: ( ) murmur ( ) thrills ( ) normal

11. ABDOMEN

Shape : ( ) round ( ) flat

Bowel Sounds: ( ) present ( ) absent
Umbilical Hernia: ( ) present ( ) absent
Omphalocele: ( ) present ( ) absent
Umbilical Cord Appearance: ( ) bluish white ( ) yellow-greenish
( ) reddish
Femoral Pulses: ( ) present ( ) absent

12. GENITALIA

Female
Labia Majora : ( ) edematous ( ) fused labia
Urinary meatus ( ) interrupted stream ( ) uniterrupted stream
Pink-stained Urine ( ) present ( ) absent

Male
Penis: ( ) ventrally curved ( ) normal
Position of urethral meatus: ( ) hypospadia ( ) Epispadia ( ) at tip of penis
Scrotum: ( ) undescended testicle ( ) descended testicle
Smegma: ( ) present ( ) absent
Foreskin: ( ) retractable ( ) unretractable
Testes: ( ) palpable ( ) not palpable

13. ELIMINATION

Urine
Color: ( ) amber ( ) blood-tinge
Transparency: ( ) clear ( ) cloudy ( ) hazy
Odor: _______________________________________________

Stool
Color: ( ) greenish black ( ) yellowish
Consistency: _________________________________
Odor: _______________________________________

14. ANUS

Anal fissures: ( ) present ( ) absent

Anal fistulas: ( ) present ( ) absent
Anus Patency: ( ) patent ( ) imperforated
Anal Reflex: ( ) present ( ) absent

15. MUSCULOSKELETAL

HIP

Barlow-Ortolani Maneuver : ( ) positive ( ) negative

Range of Motion : ( ) full ROM ( ) partial ROM
Gluteal folds: ( ) equal ( ) unequal

SPINE

Scapula: ( ) symmetrical ( ) asymmetrical

Spine: ( ) C-curve ( ) S-curve
Spina Bifida : ( ) present ( ) absent
Spina Occulta ( ) Present ( ) absent
EXTREMITIES

Hands Feet
# of digits Right :()3 ()5 ()6 # of digits Right: ( ) 3 ( ) 5 ( ) 6
# of digits Left : ()3 ()5()6 # of digits Left: ( ) 3 ( ) 5 ( ) 6
Polydactyly Polydactyly
( ) present ( ) absent ( ) present ( ) absent
Syndactyly Syndactyly
( ) present ( ) absent ( ) present ( ) absent
Phocomelia Hemimelia
( ) present ( ) absent ( ) present ( ) absent
Simean Crease Talipes:
( ) present ( ) absent ( ) present ( ) absent

16. NEUROLOGICAL

Posture: ( ) symmetrical ( ) asymmetrical

Hypertonia: ( ) present ( ) absent
Hypotonia: ( ) present ( ) absent
Tremors ( ) present ( ) absent

REFLEXES

Moro (Starle) : ( ) present ( ) absent

Palmar Grasp: ( ) present ( ) absent
Rooting: ( ) present ( ) absent
Sucking: ( ) present ( ) absent
Plantar Grasp: ( ) present ( ) absent
Stepping (dancing): ( ) present ( ) absent
Babinski ( ) present ( ) absent
Trunk Incurvation: ( ) present ( ) absent
Tonic Neck Reflex: ( ) present ( ) absent
Neck Righting Reflex: ( ) present ( ) absent
Tonic Labyrinthine Reflex : ( ) present ( ) absent
 BALLARD SCORE
Instructions: Please accomplish the scoring of the Ballard Score. Put an X
mark on the matrix on each parameter. Encircle the Maturity Rating for both
Neuromuscular and Physical Scores.

NEW MATURITY RATING & CLASSIFICATION

ESTIMATION OF GESTATIONAL AGE BY MATURITY RATING

Symbol: X – 1st Exam O – 2nd Exam

NEUROMSCULAR MATURITY

Gestation by Date: _______wks

Birth Date:
____ hr ____am/pm

APGAR
____1 min
____5 min

MATURITY RATING
Score Weeks
-10 20
-5 22
0 24
5 26
10 28
15 30
20 32
25 34
30 36
35 38
40 40
45 42
50 44
PHYSICAL MATURITY

SCORING SECTION

1st 2nd
Exam Exam
Estimated
Gest. Age wks wks
By
Maturity
Rating
Time of Date: Date:
Exam

Hour: Hour:

AM/ AM/
PM PM

Age of
Exam hrs hrs
Signature
of
Examinee MD MD
 NURSE’S NOTES

Date & Time Focus Data – Action – Reaction/Response

 BREASTFEEDING OBSERVATION AID

Mother’s HRN : _________________________ Date _________________

Baby's HRN : _______________________________ Baby's age ____________

Signs that breastfeeding is going well: Signs of possible difficulty:

GENERAL
Mother: Mother:
 Mother looks healthy  Mother looks ill or depressed
 Mother relaxed and comfortable  Mother looks tense and uncomfortable
 Signs of bonding between mother and baby  No mother/baby eye contact
Baby: Baby:
 Baby looks healthy  Baby looks sleepy or ill
 Baby calm and relaxed  Baby is restless or crying
 Baby reaches or roots for breast if hungry  Baby does not reach or root

BREASTS
 Breasts look healthy  Breasts look red, swollen, or sore
 No pain or discomfort  Breast or nipple painful
 Breast well supported with fingers away  Breasts held with fingers on areola
from nipple

BABY’S POSITION
 Baby’s head and body in line
 Baby held close to mother’s body
 Baby’s whole body supported
 Baby approaches breast, nose to nipple
BABY’S ATTACHMENT
 More areola seen above baby’s top lip
 Baby’s mouth opens wide
 Lower lip turned outwards
 Baby’s chin touches breast
 Baby’s neck and head twisted to feed
 Baby not held close
 Baby supported by head and neck only
 Baby approaches breast, lower lip/chin
to nipple
 More areola seen below bottom lip
 Baby’s mouth not open wide
 Lips pointing forward or turned in
 Baby’s chin not touching breast

SUCKLING
 Slow, deep sucks with pauses
 Cheeks round when suckling
 Baby releases breast when finished
 Mother notices signs of oxytocin reflex
 Rapid shallow sucks
 Cheeks pulled in when suckling
 Mother takes baby off the breast
 No signs of oxytocin reflex noticed

Notes:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Assessed by: _________________________________________

Student’s Signature over Printed Name
 Evidence – Based Nursing Research
(Reflection Paper)

Instructions: Search for a Research Article related to the case of your patient
and give your own reflection/insights.

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 LEARNING FEEDBACK DIARY

Learnings Problems Encountered Actions Taken Realization

SELF

PEERS

ASSIGNED
AREA

CLINICAL
INSTRUCTOR